WHO/EMC/ZDI/98.6
Guidelines for the Surveillance and Control of Anthrax in
Human and Animals. 3rd edition.
Principal Author: PCB Turnbull
World Health Organization
Emerging and other Communicable Diseases,
Surveillance and Control
This document has been downloaded from the WHO/EMC Web site. The
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WHO/EMC/ZDI./98.6
Distribution: General
Orig.: English only
Guidelines for the
Surveillance and Control
of Anthrax in Humans and Animals
THIRD EDITION
PRINCIPAL AUTHOR
PCB Turnbull
Centre for Applied Microbiology and Research
Porton Down, Salisbury, Wiltshire SP4 0JG, UK
Contributors
R Böhm
Institut für Umwelt- und Tierhygiene, Universität Hohenheim, 70593 Stuttgart, Germany
O Cosivi
Department of Communicable Diseases, World Health Organization, 1211 Geneva 27, Switzerland
M Doganay
Erciyes Universitesi, Tip Fakultesi Infeksiyon, Hastaliklari Klinigi, 38039 Kayseri, Turkey
ME Hugh-Jones
Department of Epidemiology and Community Health, School of Veterinary Medicine, Louisiana State
University, Baton Rouge, LA 70803-8404, USA
DD Joshi
National Zoonoses and Food Hygene Research Centre, Kathmandu, Nepal
MK Lalitha
Department of Microbiology, Christian Medical College and Hospital, IDA Scudder Road, Vellore
632004, Tamil Nadu, India
V de Vos
Kruger National Park, Private Bag X402, Skukuza 1350, Republic of South Africa
World Health Organization
Department of Communicable Diseases Surveillance and Response
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
Contents
Contents .............................................................................................................................................................................v
Appendix........................................................................................................................................................................ viii
Figures and diagrams...............................................................................................................................................x
Statement of commercial impartiality ........................................................................................................ xiii
1
The disease and its importance............................................................................................................ 1
2
Etiology and ecology................................................................................................................................... 1
3
2.1
Spores and vegetative forms........................................................................................ 1
2.2
Climate and other influencing factors........................................................................ 3
2.3
Strains ............................................................................................................................ 3
Anthrax in animals........................................................................................................................................ 4
3.1
Host range and susceptibility...................................................................................... 4
3.2
Incidence of anthrax in animals .................................................................................. 4
3.3
Transmission in animals.............................................................................................. 6
3.4
Pathogenesis and symptoms........................................................................................ 7
3.5
Diagnosis in animals .................................................................................................... 8
3.5.1 Differential diagnosis........................................................................................ 10
3.5.2. Retrospective diagnosis (seroconversion) ....................................................... 10
4
Anthrax in man.............................................................................................................................................10
4.1
Incidence...................................................................................................................... 10
4.2
Susceptibility. Data for risk assessments................................................................. 11
4.3
4.2.1 Historical information....................................................................................... 11
4.2.2 Infectious dose................................................................................................... 11
4.2.3 Biological warfare associations ........................................................................ 12
Epidemiology and transmission: the forms of anthrax........................................... 13
4.4
The clinical disease..................................................................................................... 14
4.4.1
4.4.2
4.4.3
4.4.4
4.4.5
5
Cutaneous anthrax............................................................................................ 14
Gastrointestinal anthrax ................................................................................... 16
Pulmonary (inhalation) anthrax....................................................................... 17
Anthrax meningitis ........................................................................................... 18
Anthrax sepsis ................................................................................................... 18
Pathogenesis and pathology..............................................................................................................18
5.1
Toxin as the cause of death ........................................................................................ 18
v
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
5.2
6
7
The virulence factors of B. anthracis ........................................................................ 18
Bacteriology....................................................................................................................................................19
6.1
Detection and isolation .............................................................................................. 20
6.2
Identification and confirmation................................................................................ 21
Treatment .........................................................................................................................................................21
7.1
Treatment of animals.................................................................................................. 22
7.2
7.1.1 General principles and approaches.................................................................. 22
7.1.2 Specific procedures ........................................................................................... 22
Treatment of humans ................................................................................................. 24
7.2.1
7.2.2
7.2.3
7.2.4
7.2.5
7.2.6
7.2.7
7.2.8
7.2.9
8
Mild uncomplicated cases ................................................................................ 24
Severe or potentially life–threatening cases .................................................... 24
Supportive treatment for cutaneous anthrax .................................................. 24
Alternatives to penicillin................................................................................... 25
Adequate doses ................................................................................................. 25
Duration of treatment ....................................................................................... 25
Treatment of anthrax meningoencephalitis..................................................... 26
Hyperimmune serum therapy.......................................................................... 26
Recurrence after treatment ............................................................................... 26
Control ...............................................................................................................................................................26
8.1
Disposal of anthrax carcasses (point X in Figure 3)................................................. 27
8.2
8.1.1 Alternatives ....................................................................................................... 27
8.1.2 Burial.................................................................................................................. 28
8.1.3 Incineration........................................................................................................ 28
8.1.4 Rendering .......................................................................................................... 29
Infection control in the management of human anthrax cases .............................. 30
8.3
Disinfection, decontamination and disposal of infected/contaminated
material (site Y in Figure 3)........................................................................................ 30
vi
8.4
8.3.1 Decontamination of manure, dung, bedding, unused feed, etc..................... 31
8.3.2 Disinfection of surfaces in rooms, animal houses, vehicles, etc. .................... 31
8.3.3 Fumigation of closed spaces – cabinets, rooms, etc. ....................................... 32
8.3.4 In the laboratory – spills, splashes, accidents.................................................. 33
8.3.5 Decontamination of liquid manure.................................................................. 35
8.3.6 Decontamination of sewage sludge ................................................................. 35
8.3.7 Treatment of water............................................................................................ 36
8.3.8 Treatment of soil ............................................................................................... 36
8.3.9 Other materials – clothing, tools, etc................................................................ 37
8.3.10 Decontamination of wool and hair .................................................................. 37
8.3.11 Hides and skins ................................................................................................. 38
8.3.12 Bone, hoof and horn.......................................................................................... 38
Prophylaxis .................................................................................................................. 39
8.5
8.4.1 The nature of protection in anthrax ................................................................. 39
8.4.2 Animal vaccines ................................................................................................ 39
8.4.3 Human vaccines ................................................................................................ 40
8.4.4 Prospective new vaccines ................................................................................. 40
Intersectoral issues: the question of eradication ..................................................... 42
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
9
Surveillance ....................................................................................................................................................43
9.1
Public health surveillance of anthrax in humans.................................................... 44
9.2
9.1.1 Specific objectives.............................................................................................. 44
9.1.2 Suggested case definition ................................................................................. 44
9.1.3 Reporting and information flow ...................................................................... 45
Veterinary surveillance of anthrax in animals ........................................................ 46
9.4
9.2.1 Specific objectives.............................................................................................. 46
9.2.2 Suggested case definition ................................................................................. 47
9.2.3 Reporting and information flow ...................................................................... 47
Recommended data analyses, presentation, reports ............................................... 49
9.5
Strategies of anthrax surveillance in animals.......................................................... 49
vii
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
Appendices
Appendix I
A.I.1
Methods ________________________________________________________________ _________ 51
General standard laboratory procedures for isolation,
identification, diagnosis and confirmation of anthrax...................................... 51
A.I.1.1
Fresh specimens from untreated animals or humans .......................... 51
A.I.1.2
Specimens from treated animals and humans...................................... 51
A.I.1.3
Specimens from old or decomposed animal specimens or
from animal products or environmental specimens ............................ 51
A.I.1.4
Suggested procedure for isolation and identification of
B. anthracis and confirmation of diagnosis............................................ 52
A.I.1.5
A.I.2
A.I.3
Molecular diagnosis ............................................................................... 52
Capsule visualisation............................................................................................ 52
A.I.2.1
Polychrome methylene blue stain (M=Fadyean reaction)..................... 52
A.I.2.2
A.I.2.1.1 Staining theory..................................................................... 55
A.I.2.1.2 Polychrome methylene blue staining procedure............... 56
A.I.2.1.3 India ink method ................................................................. 56
Induction of capsule formation ............................................................. 57
A.I.2.2.1 In blood ................................................................................ 57
A.I.2.2.2 On agar plates ...................................................................... 57
Antigen detection tests.......................................................................................... 57
A.I.3.1
Ascoli precipitin test (thermostable antigen test)................................. 57
A.I.3.2
Other antigen detection tests ................................................................. 59
A.I.4
Isolation in animals............................................................................................... 59
A.I.5
Serology .................................................................................................................. 60
A.I.6
PCR.......................................................................................................................... 60
Appendix II
Media and reagents ____________________________________________________________ 63
A.II.1
Polymyxin blood agar ........................................................................................... 63
viii
A.II.1.1
Polymyxin–lysozyme–EDTA–thallous acetate (PLET) agar................ 63
A.II.1.2
Diagnostic gamma–phage...................................................................... 64
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
Appendix III
Disinfection, decontamination and incineration of carcasses ________________ 67
A.III.1
Introduction ........................................................................................................... 67
A.III.2
Disinfectants .......................................................................................................... 67
A.III.2.1 Efficacy tests for sporicidal disinfectants .............................................. 68
A.III.2.2 Titration of available chlorine in hypochlorite solutions ..................... 68
A.III.3
Guidelines on incineration of carcasses.............................................................. 69
A.III.3.1 Pit method............................................................................................... 69
A.III.3.2 Raised carcass method ........................................................................... 70
A.III.3.3 Commercial incinerators........................................................................ 70
A.III.3.3.1 Down–directed blow torches.............................................. 70
A.III.3.3.2 Portable incinerator ............................................................. 70
A.III.3.3.3 Centralized incinerators ...................................................... 71
Appendix IV
International Zoo–Sanitary Code ________________________________ ______________ 73
Chapter 3.1.1–ANTHRAX................................................................................................................ 73
Appendix V
Vaccines _________________________________________________________________________ 75
A.V.1
General ................................................................................................................... 75
A.V.2
A.V.1.1
Veterinary vaccines ............................................................. 75
Vaccine failures in livestock ................................................................................ 76
A.V.3
Manufacturers of live spore (veterinary) vaccines............................................ 78
A.V.4
Manufacturers of human anthrax vaccines......................................................... 83
Appendix VI
Contingency plan for the prevention and control of Anthrax _________________ 85
A.VI.1
Action in the event of an outbreak of anthrax in livestock............................... 85
A.VI.2
Other actions in the event of a case, or cases, of anthrax in
livestock.................................................................................................................. 86
A.VI.3
Guidance on actions relating to milk from herds/flocks in
which anthrax has occurred.................................................................................. 87
A.VI.4
Precautions for exposed personnel...................................................................... 88
Appendix VII
Model country programmes________________________________ ____________________ 89
A.VII.1
Background ............................................................................................................ 89
A.VII.2
Templates for control problems illustrated with the experience
gained in Western Province, Zambia .................................................................. 90
Appendix VIII
Packaging, Labelling and Documentation for transport of
infectious or contaminated materials ________________________________ __________ 99
Appendix IX
References_____________________________________________________________________ 103
ix
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
Figures and Diagrams
Figure 1
Figures
top
right
(zebra),
bottom
left
(springbok) and bottom right (elephant)
Cycle of infection in anthrax. The spore is
reproduced from Culture 1997; 18 (2): 5–8, by
central to the cycle, although infection can
permission of Euromed Communications Ltd,
also be acquired through uptake of the
vegetative forms when, for example, humans
Haslemere, UK.
Figures A–F
or carnivores eat meat from an animal that
died of anthrax or when biting flies transmit
the disease.
Confirmation (see Appendix I [A.I.1 and
A.1.2]).
Figure 2
Importation from endemic to other countries
A
Spores and vegetative cells of
B. anthracis. This species belongs to
and cycles within the importing country.
Bacillus species morphological group 1;
Figure 3 see Figure 1.
the spores are centrally placed in the
Figure 4
swell.
sporangium and do not cause it to
Pictures featured in a book and on a poster
conveying the story of the problems the Liseli
B
an animal that has died of anthrax
family suffered following the death of their
stained with polychrome methylene
cows from Anthrax.
A.1.1.4.1 Flow
Capsulated B. anthracis in the blood of
blue (M'Fadyean stain). In vivo, the
diagram
of
bacilli are in short chains (in vitro, they
suggested
procedure for isolation and identification of
form endless strings). The clearly
B.anthracis and confirmation of diagnosis.
demarcated capsule surrounding dark
blue "box–car" bacilli in blood from a
A.1.1.4.2 Simplified version of A.1.1.4.1
dead animal is a definitive diagnostic
(following Route B for old animal specimens
confirmation of anthrax (unstained
or environmental samples.
"ghosts" around bacterial cells are not
Figures: front cover
acceptable for diagnosis and may be
putrefactive organisms).
Terminal haemorrhage from the nose, mouth
and/or anus following sudden death is
characteristic
of
anthrax
and
plays
C
an
Colonies of B. anthracis on selective
PLET agar after 42 hours at 37 oC. The
essential role in the cycle of infection of
colonies are "bee’s–eye" in appearance:
Bacillus anthracis (see Figure 1, p.2).
dome–shaped with a matt texture but
not dry.
Top left figure (cow) kindly supplied by Mr Nigel
Durnford,
Trading
Standards
Department,
Gloucestershire County Council, Gloucester, UK.
x
D
On blood agar, the colony is non–
haemolytic and characteristically tacky;
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
it can be teased up in the manner
shown with an inoculating loop. Note
also the curly tails sometimes seen with
B. anthracis colonies.
E
Figures G–L (see Section 8.1.3 and
Appendix III [A.III.3]):
G to J show incineration of an anthrax
carcass using a commercial incinerator.
B. anthracis (east and west) and two
Note in G the bag to prevent further
non–anthrax Bacillus species (north and
spillage of blood from the nose and
south) on blood agar. B. anthracis is
mouth and that, in H, incineration is
non–haemolytic and sensitive to the
from underneath the carcass. Note also
diagnostic "gamma" phage and to
in J that the ground underneath the
penicillin. Note the haemolysis around
carcass has been well–scorched.
the growth of the top culture and that
neither top or bottom cultures show
K and L show an alternative approach to on–
site incineration using down–directed
sensitivity to phage or penicillin.
F
PCR is useful for confirming the
virulence of an isolate. Lanes 2 and 6
show the presence of both capsule and
toxin genes, representing fully virulent
blow–torches.
Figures G–J kindly supplied by Mr Nigel
Durnford,
Trading
Standards
Department,
Gloucestershire County Council, Gloucester, UK;
B. anthracis. Lane 3 shows the presence
Figures K–L kindly supplied by the Notifiable
of the toxin gene only; the B. anthracis
Diseases
would be similar to the Sterne vaccine
Fisheries and Food, Tolworth, UK.
strain 34F2. Lane 4 shows the presence
of the capsule gene only; the B. anthracis
Section,
Ministry
of
Agriculture,
Figures M–R
would be similar to the Pasteur vaccine
Stages in the development and resolution of
strain. The DNA in lane 5 lacks both
cutaneous anthrax lesions (see Section 4.4.1).
genes. Lane 7 is a water control. (Lanes
M
As first seen (day 1)
N
On day 2 or 3
Figures A and F kindly supplied by Jane
O
Day 4
Bowen, CAMR, Porton Down, UK.
P
Day 6
Q
Day 11
R
Day 150. Resolution of all but the most
1 and 8 are molecular weight markers).
(See Appendix I [A.I.6]).
Figure D kindly supplied by Mr R. Charlton,
Bulawayo, Zimbabwe; reproduced from Topley &
Wilson's Principles of Bacteriology, Virology and
Immunity, 8th ed, Vol 2, Figure 9.7, by permission
severe lesions is usually complete
of Edward Arnold/Hodder & Stoughton.
without surgical intervention, leaving
only light scarring. Sensitive areas, such
as the eyelid, may need surgical
attention.
xi
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
Not visible in these pictures is the extensive
accompanying oedema which is an important
diagnostic sign, and can be life threatening
from the risk of asphyxiation when the lesions
are on the face or neck.
Figures M, N, P, R kindly supplied by
Dr W.E. Kobuch, 07–Gynecologie Obstetrique,
Toulouse, France. Figure P reproduced from
Figure 15–1 of Medical Microbiology, 4th ed,
University of Texas Medical Branch, Galveston,
USA, by permission of the editor.
Figures O, Q kindly supplied by Dr R.
Pfisterer, Grüt, Switzerland. Reproduced from
Schweiz med Wschr 1991; 121:813–25 by
permission of the editor.
xii
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
Statement of
commercial impartiality
A number of suggested commercial sources of materials are given
in this document in an attempt to meet the practical needs of the
readers. These are sources known to the authors. Their inclusion
does not imply endorsement of the products by the World Health
Organization, which recognizes that equivalent products from
other sources may be equally satisfactory.
xiii
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
1
The disease and its importance
Anthrax is primarily a disease of herbivores although few, if any, warm blooded species are
entirely immune to it. From earliest historical records until the development of an effective
veterinary vaccine mid–way through the present century (Sterne, 1937; Sterne et al., 1939),
together with the subsequent advent of antibiotics, the disease was one of the foremost causes
of uncontrolled mortality in cattle, sheep, goats, horses and pigs worldwide. Humans almost
invariably contract anthrax directly or indirectly from animals. Today the Office international
des épizooties, Paris, France (OIE), reports (OIE, 1997a) show that the disease is still enzootic in
most countries of Africa and Asia, a number of European countries and countries/areas of the
American continent and certain areas of Australia; it still occurs sporadically in many other
countries.
2
Etiology and ecology
Anthrax is a bacterial disease caused by the spore–forming Bacillus anthracis, a Gram positive,
rod–shaped bacterium (see section 6).
2.1 Spores and vegetative forms
When conditions are not conducive to growth and multiplication of the bacilli, they tend to
form spores. Sporulation requires the presence of free oxygen; within the anaerobic
environment of the infected host the organism is in the vegetative form.
Although the vegetative forms of B. anthracis grow and multiply readily on or in normal
laboratory nutrient agars or broths, the evidence is that they are more “fragile” than the
vegetative forms of other Bacillus species, dying more spontaneously in simple environments
such as water or milk, and more dependent on sporulation for species survival (Turnbull et al.,
1991; Bowen et al. 1992; Lindeque 1994). B. anthracis is, to all intents and purposes, an obligate
pathogen.
The spore forms are markedly resistant to biological extremes of heat, cold, pH, desiccation,
chemicals (and thus to disinfection), irradiation and other such adverse conditions. Therefore,
the spore forms are the predominant phase in the environment and it is very largely through
the uptake of spores that anthrax is contracted.
Within the infected host the spores germinate to produce the vegetative forms which multiply,
eventually killing the host. A proportion of the bacilli released by the dying or dead animal (see
Section 5) into the environment (usually soil under the carcass) sporulate, ready to be taken up
by another animal. This cycle of infection is illustrated in Figure 1.
1
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
Figure 1. Cycle of infection in anthrax. The spore is central to the cycle, although infection
can also be acquired through uptake of the vegetative forms when, for example, humans or carnivores
eat meat from an animal that died of anthrax or when biting flies transmit the disease.
The rate and extent of sporulation by vegetative cells shed from infected animals is affected in a
complex manner by the environmental conditions into which they fall. Temperature, pH,
oxygen availability and the presence of certain cations such as Mn++ are the principal
influencing factors.
Spores will germinate outside an animal if they fall into appropriate conditions, i.e. a
temperature between about 8o and 45oC, a pH between about 5 and 9, a relative humidity
greater than 95% and the presence of adequate nutrients. The extent to which subsidiary
cycles of germination, multiplication and resporulation occur in the environment remains a
topic of debate, but research (Bowen et al., 1992; Turnbull et al., 1991; Lindeque, 1994) suggests
that the level of nutrient required for this to become possible is unlikely to occur very
frequently under natural conditions. In fact, it seems that the fragile vegetative forms die
rapidly in most environmental conditions, depending on sporulation in a proportion of the
population for passing the infection to the next host (Bowen et al., 1992; Lindeque, 1994).
2
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
2.2 Climate and other influencing factors
There is little dispute that anthrax is a seasonal disease; its incidence in any one place is related
to temperature, rains or drought; however, examination of the literature shows that the
conditions which predispose to outbreaks differ widely from location to location. Climate
probably acts directly or indirectly by influencing the way in which an animal comes into
contact with the spores (for example, grazing closer to the soil in dry periods when grass is
short or sparse, or movement of herds to restricted sites when water becomes scarce), or by
affecting the general state of health of the hosts and thereby affecting their level of resistance to
infection.
Much has been written and hypothesized about the effects of season, rainfall, temperature, soil,
vegetation, host condition and population density on the epidemiology of anthrax, but little
agreement exists on the roles played by these factors in the incidence of the disease. Most of the
theories are based on concepts of conditions under which B. anthracis may germinate and multiply
in the environment, but hard scientific supportive data are not readily available and, as said in 2.1,
the conditions under which multiplication in the environment could take place probably only
occur in exceptional circumstances.
No one model satisfactorily explains the varying observations on the relationship between the
factors listed above and the incidence and persistence of anthrax in a locality. This is an area
worthy of further structured research.
2.3 Strains
B. anthracis appears to be one of the most monomorphic species known. That is to say, isolates
from whatever type of source or geographical location are almost identical phenotypically and
genotypically. Phenotypically, strain differences are only apparent in non–quantifiable or semi–
quantifiable characteristics, such as colonial morphology, flocculation in broth culture, cell size,
LD50 in animal tests, and so on. The biochemical, serological or phage typing methods available in
the case of other pathogens have proved of no value for identifying different strains of B. anthracis.
At the molecular level, genomic differences have also proved hard to detect, although, some
progress is being made in attempts to devise chromosomally–based strain differentiation systems
Henderson 1996; Anderson et al. 1996; Keim et al. 1997; Jackson et al. 1997.
It seems reasonable to attribute this exceptional degree of species monomorphism to the fact
that B. anthracis encounters opportunities to multiply less often than most other bacterial and
pathogenic species. Given the truth of the statements in 2.1 and 2.2 that opportunities to
multiply in the environment are rare, multiplication cycles depend almost exclusively on
infections in animal hosts – which, in turn, may only occur following considerable time
intervals between sequential hosts. Furthermore, since multiplication occurs almost exclusively
in the animal host, the vegetative form of the organism is rarely exposed to the mutagens,
phages or other environmental factors responsible for strain variation in other bacterial species.
3
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
3
Anthrax in animals
3.1 Host range and susceptibility
As said at the outset (Section 1), anthrax is primarily a disease of herbivores. However, reports
of its occurrence in dogs scavenging anthrax carcasses and in carnivorous animals in zoological
gardens and wildlife sanctuaries or parks are not entirely uncommon, though outbreaks
affecting large numbers of carnivorous animals are very rare. Published LD50s for anthrax by
the parenteral route range from <10 for a guinea pig through 3 x 103 for the rhesus monkey, 106
for the rat, 109 for the pig and 5 x 1010 for the dog (Watson and Keir, 1994). Minimum infectious
dose (MID) estimates are only rarely available, but an aerosol MID for sheep of 35 000 spores
has been recorded (Fildes, 1943). De Vos and Scheepers (1996) record that 100 spores of a strain
isolated from a kudu in the Kruger National Park consistently resulted in death from anthrax
when administered parenterally in impala. In another recent study on 50 pigs given doses of 107
to 1010 spores in feed containing grit (Redmond et al., 1997), the majority showed clinical illness
with recovery, and just two died with confirmed anthrax 6 and 8 days respectively after
ingestion of the spores; these were estimated to have received 1.6 x 107 and 7.8 x 107 spores
respectively.
Since it is thought that animals generally acquire anthrax by ingestion of spores, and that some
sort of lesion is necessary for the establishment of infection (see 3.3), LD50s, particularly
parenterally determined, only provide a rudimentary guide to natural susceptibility.
Extrapolating experimental findings to the natural situation must also be done cautiously,
taking into consideration the many factors influencing infectivity, such as the strain of
B. anthracis, the route of infection, the specie, breed or strain and state of health of the animal
tested, the times and sites at which tests are done and so on.
3.2 Incidence of anthrax in animals
The following information on the occurrence of anthrax in animals has been derived from
official reports (OIE, 1997) as well as from data collected from other sources (Hugh-Jones;
personal communication).
During the past three decades, there has been a progressive global reduction in livestock cases
in response to national programmes. As a result, the disease in animals is now truly absent or
only sporadic in the middle and higher latitudes of Europe; it is still common in the European
countries adjoining the Mediterranean (Greece, Italy, Spain, Turkey and Yugoslavia). In
Canada, apart from its continued incidence in bison in the MacKenzie Bison Range, North West
Territory, and in the Wood Buffalo National Park, northern Alberta, it is sporadic in southern
Alberta and Saskachewan, with a recent singular outbreak in Ontario. In the USA it is confined
to a few persistent pockets with sporadic cases in South Dakota, Nebraska, and Oklahoma but
probably a hyperendemic situation persists throughout the south western quadrant of Texas.
4
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
The true situation in Latin America awaits definition; under–reporting and failure to diagnose
unexpected livestock deaths certainly occurs, especially in small ruminants; it is enzootic in
Central America, Mexico and Guatemala, with decreasing occurrence as one goes farther
south—it is absent in Belize, as it is throughout the Caribbean with the exception of Haiti.
Anthrax is enzootic in Peru, Bolivia and Venezuela.
In South Africa, the annual number of outbreaks is less than 5 and occasionally zero, despite the
continued occurrence of the disease in wildlife in the various parks. Good control programmes
have been established in Botswana, Zimbabwe and Zambia, but the disease remains well–
known in the latter two countries at least. In equatorial African countries, anthrax is enzootic or
hyperenzootic.
The Middle Eastern and adjoining countries of former USSR republics continue to experience
hyperendemic anthrax. Anthrax is enzootic in southern India but is less frequent to absent in
the northern Indian states where the soil is more acid, while in Nepal it is endemic.
Some south–east Asian countries are severely affected—Myanmar, Vietnam, Cambodia,
western China—while Thailand used to be free, now it is endemic and continually threatened
and afflicted by its neighbour. Malaysia and Taiwan are free, and the disease is limited to single
regions of the Philippines and Indonesia. All these countries differ from the rest of the world in
that pigs and water buffalo, as opposed to ruminants, are the animals commonly affected.
As countries become free of anthrax or the annual incidence of outbreaks approaches unity, the
numbers of animals affected in an outbreak increase. This seems to be due to the decreasing
veterinary experience in recognizing cases and in dealing appropriately with outbreaks. The
mere absence of reported livestock anthrax does not mean that a country is free of the disease.
Reporting deficiencies and insufficient examination of unexpected livestock deaths are common
throughout the world. Also, while civil unrest in northern latitudes can be expected to result in
a fall in anthrax cases, in warmer countries, especially in Africa and Asia, civil wars invariably
result in anthrax epidemics in livestock, which then readily spill over into human populations.
The reason for this is that the northern countries import meat and bone meal and other
commonly contaminated materials but imports are cut off in times of war. For example,
Norway, which was occupied and pillaged in World War II, quickly ceased to experience
outbreaks of anthrax; meanwhile the disease continued unabated in neutral Sweden. In
contrast, during the civil war in Southern Rhodesia/Zimbabwe at the end of the 1970s, livestock
vaccination ceased and by the end of the war there had been some 10 000 human cases, as
compared with the previous normal annual rate of a dozen cases or less (Turner, 1980; Davies,
1982).
5
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
3.3 Transmission in animals
In economic and public health terms, the importance of the disease lies in its ability to affect
large numbers of livestock at one time. Carcasses then pose a hazard to humans and other
animals both in the vicinity and at a distance through their meat, hides, hair, wool or bones.
Hides, hair, wool and bones may be transported large distances for use in industries, feedstuffs
or handicrafts. Livestock may acquire the disease through contaminated feedstuffs or from
spores that have reached fields in sewage sludge.
Although anthrax has been recognized for centuries, much remains unknown about the disease,
including the precise manner by which grazing animals acquire it. The sporulated forms shed
by an animal dying or dead from anthrax generally provide the source of infection of other
animals (Figure 1). It is generally assumed that ingestion of the spores while grazing is a
frequent mode of uptake; since B. anthracis is apparently non–invasive, it is believed a lesion is
necessary for the initiation of infection. In view of associations between times of higher
incidence and dry, hot conditions, theories have arisen that, at such times, the animal is forced
to graze dry, spiky grass close to the soil. The spiky grass and grit produce the gastrointestinal
lesions and if the soil is contaminated with anthrax spores, there is a high chance of infection
occurring.
In countries with advanced agriculture, contaminated feedstuffs are or have been a common
and significant source of infection, especially for dairy cows. The source can either be
improperly treated locally produced meat and bone meals salvaged from moribund stock or
imported infected bones/contaminated meat and bone meals. Cross–contamination can occur
during shipping if the hulls of cargo ships and other containers are not cleaned out between
shipments or if infected dry hides are placed on top of feed; this practice has in the past
produced contaminated vegetable high–protein feeds which normally would not be expected to
contain B. anthracis spores. Similar cross–contamination following the re–use of feed sacks has
resulted in outbreaks of anthrax.
In England, Germany, Italy and Canada, pastures flooded by tannery waste water historically
have posed a long–recognized hazard to grazing stock (Figure 2).
The examination of associations between climatic conditions and peak anthrax periods around
the world have resulted in an number of other theories. Some contribute to the hypothesis that
an animal can harbour the spores for long periods only manifesting the disease when stressed
or compromised immunologically; seasonal stress may play a role in this regard. Others believe
that acquisition of the disease by inhalation of spore–laden dust is not infrequent. The extent to
which this might occur would vary with season. It is widely accepted that, in some regions,
certain types of flies transmit anthrax; again this would be associated with season.
6
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
Figure 2. Importation from endemic to other countries and cycles within the importing country.
3.4 Pathogenesis and symptoms
Except when taken up by the pulmonary route, B. anthracis needs a lesion through which to
enter the body. Following entry, the spores, which may have commenced germination, are
carried to the lymphatics where they multiply and, in terms used by workers in the 1950s,
continuously feed the blood stream with the vegetative bacilli in a manner analogous to
continuous culture. Initially, during the incubation period, the bacteria are filtered out by the
spleen and other parts of the reticuloendothelial system. However, the system finally breaks
down due to toxin action and, during the last few hours of life (fulminant systemic phase), the
bacteria build up rapidly in the blood (doubling time approximately 0.75 to 2 hours depending
on host species) to levels of >108/ml together with massive toxaemia at the time of death. The
action of the toxin on the endothelial cell lining of the blood vessels results in their breakdown,
internal bleeding and the characteristic terminal haemorrhage to the exterior which is an
essential part of the organism’s cycle of infection (Figure 1 and front cover).
The incubation period in the susceptible herbivore ranges from about 36 to 72 hours and leads
into the hyperacute systemic phase, usually without easily discernible prior symptoms. The first
signs of an anthrax outbreak are one or more sudden deaths in the affected livestock, although
farmers may reflect retrospectively that the animals had shown signs such as having
been off their food or having produced less milk than usual. During the systemic phase, the
animals become distressed, appear to have difficulty breathing and cease eating and drinking.
Swellings in the submandibular fossa may be apparent; temperatures may remain normal for
most of the period or may rise. The animal can remain responsive to treatment well into this
7
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
period but if treatment fails it lapses into coma followed by death from shock. In highly
susceptible species, the period between onset of visible symptoms and death may be just a few
hours; the course of these events is more protracted in more resistant species.
3.5 Diagnosis in animals
The history is of major importance in the diagnosis of anthrax. Clinical manifestations to look
for are:
Ruminants: Sudden death, bleeding from orifices, subcutaneous haemorrhage, without prior
symptoms or following a brief period of fever and disorientation should lead to suspicion of
anthrax.
Equines and some wild herbivores: Some transient symptoms  fever, restlessness, dyspnoea,
agitation  may be apparent.
Pigs, carnivores, primates: Local oedemas and swelling of face and neck or of lymph nodes,
particularly mandibular and pharyngeal and/or mesenteric.
At death in most susceptible species (the pig being a notable exception), the blood contains 107
to 108 bacilli per ml provided the animal has not been treated (numbers may also be lower in
immunized animals which succumb to the disease). For reasons unknown, numbers of
B. anthracis at death are very low in pigs (hundreds per millilitre or less).
A blood smear should be obtained with a swab from a small incision in the ear or from an ear
clipping (the ear is usually recommended as being accessible, supplied with an extensive
capillary network), or by means of a syringe from an appropriately accessible vein (the blood
characteristically clots poorly or not at all upon death in anthrax victims and is dark and
haemolysed). The smear is dried, fixed and stained with polychrome methylene blue
(M’Fadyean stain) as described in Appendix I (A.I.2.1.2). Large numbers of the capsulated
bacilli will be seen in smears from relatively fresh carcasses of most species (see preceding
paragraph). A Gram stain will not reveal the capsule and may result in mistaken diagnosis,
particularly if the carcass is not very fresh. B. anthracis does not compete well with putrefactive
bacteria and, with increasing age of the carcass, the capsulated bacilli become harder to
visualize (see also four paragraphs below).
The bacterium can also be cultured from the blood or from a swab of a ear clipping or other
appropriate specimen on blood agar or other nutrient agar (see Appendix I). The haemorrhagic
nasal, buccal or anal exudate will also carry large numbers of B. anthracis which can be
cultured from swabs or from samples contaminated with the exudate.
If anthrax is suspected the carcass should not be opened; contamination of the environment by
spilled body fluids with subsequent spore formation, is thereby avoided. If, mistakenly, the
carcass has been opened, the dark unclotted blood and markedly enlarged haemorrhagic spleen
are immediately apparent. The mesentery may be thickened and oedematous and peritoneal
8
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
fluid may be excessive. Petechial haemorrhages may be visible on many of the organs and the
intestinal mucosa may be dark red and oedematous with areas of necrosis. Where anthrax has
been diagnosed after a carcass has been opened, special attention should be paid to
decontamination of the site at which the postmortem was carried out and of the tools and
materials that were used (see section 8).
In horses, the intestine and parenchymatous organs may be less affected than in sheep and
cattle and the subcutaneous and intramuscular tissues may be oedematous. In pigs, as indicated
above, blood smears may not reveal the capsulated bacilli and, if cervical oedema is
present, smears and cultures should be made from fluid from the enlarged mandibular and
suprapharyngeal lymph nodes. If intestinal anthrax is responsible for death in pigs, this may
only become apparent at necropsy; smears and cultures should be made from the
mesenteric fluid and lymph nodes. In other animals, in addition to any haemorrhagic exudates
that may be observed, severe inflammation and oedematous swelling of the lips, tongue, gums,
jowls and throat may be diagnostic indicators.
In the unopened carcass, the bacilli, unable to sporulate in the absence of oxygen, are
destroyed by the putrefactive processes. Smears, as a diagnostic procedure, become unreliable
about 24 hours after death although “shadons” (capsular material) may still be observed some
time after the bacilli themselves can no longer be seen. B. anthracis can often be cultured from
carcass skin residues for some days after death but, with increasing length of time
between death and examination, this becomes progessively less easy. Diagnosis then becomes
increasingly dependent on isolation of spores from soil or other environmental samples
contaminated by the oral, buccal or anal exudates.
As mentioned in Appendix I (A.I.1.2), it may not be possible to find the bacilli in smears or to
isolate B. anthracis from animals that were treated before death; treatment can sterilize the blood
and tissues but, if sufficient toxin has been formed, the animal may still go on to die.
The thermostable antigen precipitin test devised by Ascoli (1911) (see Appendix I [A.I.3.1]) is
still used in several countries of Europe and the Far East for detecting residual antigens in tissue
in which it is no longer possible to demonstrate B. anthracis microscopically or by culture.
However, it should be borne in mind that the antigens being detected are shared by other
Bacillus species and that the test relies on the fact that, if Bacillus antigens are present in the
tissues, this probably represents B. anthracis infection since infections with other Bacillus species
are rare. Care has to be taken if the tissue being examined has been grossly contaminated with
environmental materials (soil, sand, etc.) which frequently harbour large numbers of
other Bacillus species.
A simple, rapid and highly sensitive and specific chromatographic device, utilising a
monoclonal capture antibody detecting the anthrax–specific protective antigen, has now been
designed (Burans et al., 1996) and hopefully will become available in the near future as a more
reliable and more sensitive alternative to the Ascoli test.
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Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
3.5.1 Differential diagnosis
For differential diagnosis, other causes of sudden death should be considered. Amongst these
are botulism, blackleg (Clostridium chauvoei), peracute babesiosis, chemical poisoning (heavy
metals, other poisons), ingestion of toxic plants, snake bite, lightning strike or metabolic
disorders such as lactic acidosis, magnesium deficiency, bloat. A recent outbreak of Rift Valley
Fever in Kenya was initially thought to be anthrax (WHO, 1997a).
3.5.2. Retrospective diagnosis (seroconversion)
Historically, there has been little need for serological support for the diagnosis of anthrax in
animals. Either the animal had anthrax, recognized from the recent history of the herd or site,
and was treated accordingly, or it died. Most of the interest in developing serological testing has
been for research on humoral responses in humans, and—to a lesser extent—animals, to
vaccines and for epidemiological studies involving naturally acquired seroconversion in
humans, livestock and wild mammals.
Currently accepted as the best serological procedure is the ELISA in microtitre plates coated
with the Protective Antigen (PA) component of the anthrax toxin at 3 –5 µg/ml in high pH (9.5)
carbonate coating buffer. The toxin antigens appear to be truly specific for B. anthracis, although
there is at present no commercial source of these. This tends to mean that anthrax serology is
currently confined to a few specialist laboratories. Various versions of the ELISA exist and can
be found in standard laboratory manuals; any version will do for anthrax serology, although
certain sera appear to be more "sticky" than others. A useful tip appears to be to use
reconstituted dried milk as the blocking agent and to raise its concentration until control
negative sera are giving reliable negative results. For bovine sera, this may be a 10% suspension
or higher.
Examples of the successful field application of anthrax serology are given elsewhere (Turnbull
et al., 1992; Redmond et al., 1997).
4
Anthrax in humans
4.1 Incidence
The major sources of human anthrax infection are direct or indirect contact with infected
animals, or occupational exposure to infected or contaminated animal products. Other possible
sources are rare and epidemiologically trivial. Human anthrax incidence is dependent on the
level of exposure to affected animals and national incidence data for non–industrial cases reflect
the national livestock situation. Historical analysis of epidemiological data globally reveals the
following approximate ratios: (a) one human cutaneous anthrax case to ten anthrax livestock
carcasses; (b) one incident of enteric human anthrax to 30–60 anthrax–infected animals eaten; (c)
in humans, 100–200 cutaneous cases for each enteric case that occurs.
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Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
Industrial anthrax incidence data can be inferred from the volume and weight of potentially
affected materials handled or imported, taking into account the quality of prevention, such as
vaccination of personnel and forced ventilation of the workplace. These relationships are
essentially all that can be used for many countries where human anthrax is infrequently,
erratically or incompletely reported. In addition, certain countries suppress anthrax reporting at
the local or national levels.
Human case rates for anthrax are highest in Africa, the Middle East and central and southern
Asia. Where the disease is infrequent or rare in livestock, it is rarely seen in humans.
4.2 Susceptibility. Data for risk assessments
4.2.1 Historical information
Circumstantial evidence indicates that man is moderately resistant to anthrax. Before vaccines
and antibiotics became available, and at a time when understanding of industrial hygiene was
relatively basic, workers in at–risk industrial occupations processing animal products were
exposed to significant numbers of anthrax spores on a daily basis. In Britain, 354 cases of
anthrax in such industries were notified during the 13–year period 1899–1912 (Anon, 1918).
Although the numbers of persons exposed is not known, it must have been many thousands,
and the number of cases clearly represented only a very small proportion of the number
exposed.
In 4 mills in the USA, in which unvaccinated workforces, varying in size from 148 to 655, were
“chronically exposed to anthrax”, annual case rates were only 0.6 to 1.4% (Brachman et al.,
1962). In one mill, workers were found to be inhaling 600 to 1300 anthrax spores over an 8–hour
shift without ill effect (Dahlgren et al., 1960) and in two goat–hair mills, B. anthracis was
recovered from the nose and pharynx of 14 of 101 healthy persons. Despite extensive exposure
to anthrax, cases among workers in wildlife reserves are exceedingly rare (Quinn and Turnbull,
1998).
Nevertheless, outbreaks and epidemics do occur in humans; sometimes these are sizeable, such
as the epidemic in Zimbabwe which began in 1979, was still smouldering in 1984–5 and had by
that time affected many thousands of persons, albeit with a low case fatality rate (Turner, 1980;
Davies 1982; Kobuch et al. 1990). Occasionally, the case fatality rates are substantial, such as in
the Sverdlovsk incident in Russia in 1979 (Abramova et al., 1993; Meselson et al., 1994). The
outbreak in a mill in New Hampshire, USA, in 1957 was not associated with any unusual
change in occupational exposure but seems to have been an isolated event within a prolonged
period of exposure (Brachman et al., 1960).
4.2.2 Infectious dose
Infectious doses, which have not been established for man, and the severity of the resulting
infection clearly depend on several factors such as route of infection, nutritional and other
11
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
states of health on the part of the infected person, and probably on the relative virulence of the
infecting strain. For the purpose of risk assessments, dependency on information from animal
tests is unavoidable. The published data on infectious and lethal doses in animals have been
collated elsewhere (Watson and Keir, 1994).
Cutaneous infections. It probably does not take many spores to initiate a cutaneous infection, but
it is generally accepted that the spores must gain access to subepidermal tissue through a cut or
abrasion before this can occur and risk of infection reflects the chance of this happening. This
risk is greatly reduced in at–risk occupations by appropriate clothing and gloves, dressing of
wounds, and other hygienic practices.
Pulmonary (inhalation) infections. Recorded inhalation LD50s in non–human primates range from
2500 to 760 000 spores (Meselson et al., 1994; Watson and Keir, 1994). The US Department of
Defence bases its strategies on an estimate that the LD50 for humans is 8000 to 10 000 spores
(Meselson et al., 1994). However the only hard data on inhalation infectious doses in humans
come from the studies in goat hair processing mills referred to in 4.2.1. In any event, substantial
exposure is evidently necessary before the risk of inhalation anthrax becomes significant. In a
recent study (Turnbull et al., 1998) the highest levels found in air sampled 3 to 9 m downwind
from disturbed dry, dusty anthrax carcass sites in Namibia were 20 to 40 colony–forming units
of spores per cubic metre. This corresponds to the conservative estimate that it would require
about 2.5 minutes for an average human undergoing moderate activity to inhale 1 spore. It is,
furthermore, well established that, at sizes above 5 µm, particles face increasing difficulty in
reaching the alveoli of the lungs. The likelihood of inhaled spores penetrating far enough to
induce inhalation anthrax therefore depends greatly on the size of the particles to which they
are attached.
The overall conclusion from the available evidence is that the risks of pulmonary anthrax
outside industrial situations are very low.
Oral route infections. There is very little information on infectious doses by the oral route, but
what is true for the skin is probably largely true for the oropharyngeal and gastrointestinal
epithelium. The chance of infection is likely to be enhanced by, if not dependent on, the
existence of a lesion in the epithelium through which spores can gain entry and establish an
infection.
Treatability. The fact that anthrax is readily treated if diagnosed at a sufficiently early stage of
infection also needs to be taken into account when assessing risks. Awareness of the likelihood
of exposure having taken place is clearly an important part of the equation.
4.2.3 Biological warfare associations
In the developed parts of the world where it is now seen rarely, anthrax has developed
something of a “doomsday bug” status in the mind of the public, and the name frequently
engenders unnecessary fear, for example, in relation to contaminated burial or industrial (e.g.
12
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
tannery) sites. This anxiety results from the association of anthrax with the topic of biological
warfare.
There is, in fact, no conflict between the statements and evidence given in 4.2.1 and 4.2.2 that
humans are fairly resistant to fatal anthrax infection and the possible aggressive use of anthrax
spores. The “worst case” natural contamination in the environment is found at the carcass sites
of animals that have died of anthrax. In a study in Namibia of 106 such sites, the highest
contamination level found was just over 1 million anthrax spores per gram of soil, but 79% had
less than 1000 per gram and 25% less than 10 per gram (Lindeque and Turnbull, 1994). Levels in
other types of inadvertently contaminated environments (soils at tannery sites, horsehair
plaster, etc.) rarely exceed a few units or tens of spores per gram (Turnbull, 1996). Natural
environmental exposure to infectious doses in the normal course of human life and endeavour
is, therefore, a fairly unlikely event.
Aggressive scenarios, in contrast, envisage exposures to overwhelmingly massive doses (many
millions of spores) which can only be created artificially. The Figure of 100 kg of dried anthrax
spores, given in one article (Taylor, 1996) on the subject as technically feasible for aggressive
delivery, represents dose levels in the order of 1013 human LD50s. It must be supposed that this
could cause substantial devastation to human and animal communities within selectively
targeted areas. The public health implication of deliberately induced anthrax outbreaks and its
use as a biological weapon have been reviewed elsewhere (WHO, 1970).
4.3 Epidemiology and transmission: the forms of anthrax
Anthrax in humans is classically divided in two ways. The first type of classification, which
reflects how the occupation of the individual led to exposure, differentiates between non–
industrial anthrax, occurring in farmers, butchers, knackers, veterinarians and so on, and
industrial anthrax, occurring in those employed in the processing of bones, hides, wool and
other animal products. The second type of classification, reflecting the route by which the
disease was acquired, distinguishes between cutaneous anthrax acquired through a skin lesion,
gastrointestinal tract anthrax contracted from ingestion of contaminated food, primarily meat
from an animal that died of the disease, or conceivably from ingestion of contaminated water
and pulmonary (inhalation) anthrax from breathing in airborne anthrax spores.
Non–industrial anthrax, resulting from handling infected carcasses, usually manifests itself as
the cutaneous form; it tends to be seasonal and parallels the seasonal incidence in the animals
from which it is contracted. Cutaneous anthrax transmitted by insect bites and intestinal
anthrax from eating infected meat are also non–industrial forms of the disease. Industrial
anthrax also usually takes the cutaneous form but has a far higher probability than non–
industrial anthrax of taking the pulmonary form through inhalation of spore–laden dust.
13
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
Humans almost invariably contract anthrax directly or indirectly from infected animals.
Records of person–to–person spread or laboratory–acquired anthrax are rare (Heyworth et al.,
1975; Collins 1988; Lalitha et al., 1988; Quinn and Turnbull, 1998).
It is generally believed that B. anthracis is non–invasive and cutaneous and gastrointestinal tract
anthrax infection require entry through a small cut, abrasion or other lesion (insect bite, ulcer,
etc.). Thus anthrax eschars are generally seen on exposed regions of the body, mostly on
the face, neck, hands and wrists.
As inferred earlier, in some countries mechanical transmission by biting insects is believed to be
at least an occasional mechanism by which anthrax is contracted by humans (Rao and
Mohiyudeen, 1958; Davies, 1983); that this can happen has been demonstrated experimentally
(Sen and Minett, 1944; Turell and Knudson, 1987).
4.4 The clinical disease
Cutaneous anthrax is said to account for 95% or more of human cases globally. All three
forms, cutaneous, gastro–intestinal tract and pulmonary, are potentially fatal if untreated, but
the cutaneous form is often self–limiting. Data from pre–antibiotic and vaccine days indicate
that 10–20% of untreated cutaneous cases might be expected to result in death (Anon, 1918).
With treatment, less than 1% are fatal.
Overt gastrointestinal tract and pulmonary cases are more often fatal, largely because they go
unrecognized until it is too late for effective treatment. However, serological and
epidemiological evidence suggests that undiagnosed low–grade gastrointestinal tract or
pulmonary anthrax with recovery can also occur, and may not be infrequent, among exposed
groups (Brachman et al., 1960; Norman et al., 1960; Sirisanthana et al., 1988; Van den Bosch,
1996).
Development of meningitis is a dangerous possibility in all three forms of anthrax.
4.4.1 Cutaneous anthrax
The incubation period ranges from as little as 9 hours to 2 weeks, mostly 2 to 6 or 7 days.
The general scenario is as follows:
Day 0
Entry of the infecting B. anthracis (usually as spores) through a skin lesion (cut,
abrasion, insect bite, etc.).
Days 2–3
A small pimple or papule appears (see Figures M–R).
Days 3–4
A ring of vesicles develops around the papule. Vesicular fluid may be exuded.
Unless the patient was treated, capsulated B. anthracis can be identified in polychrome
methylene blue–stained (M’Fadyean stain) smears of this fluid and isolated on conventional
agars, preferably blood agar (see Appendix I). Marked oedema starts to develop. Unless there is
14
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
secondary infection, there is no pus and the lesion is not painful, although painful
lymphadenitis may occur in the regional lymph nodes.
Days 5–7
The original papule ulcerates to form the characteristic eschar. Topical swabs will not
pick up B. anthracis. Detection by polychrome methylene blue–stained smears or isolation
requires lifting the edge of the eschar with tweezers (this gives no pain unless there is
secondary infection) and obtaining fluid from underneath. The fluid will probably be sterile if the
patient has been treated appropriately. Oedema extends some distance from the lesion. Clinical
symptoms may be more severe if the lesion is located in the face, neck or chest. In these more
severe forms, clinical findings are high fever, toxaemia, regional painful adenomegaly and
extensive oedema; shock and death may ensue.
Day 10
(approximately).
The eschar begins to resolve; resolution takes almost six weeks and is not hastened by
treatment. A small proportion of cases, if untreated, develop systemic anthrax with hyperacute
symptoms.
4.4.1.1 Differential diagnosis
Boil (early lesion), orf, vaccinia, glanders, syphilitic chancre, erysipelas, ulcer (especially
tropical). These lack the characteristic oedema of anthrax. The absence of pus, the lack of pain,
and the patient’s occupation may provide further diagnostic pointers. The outbreak of Rift
Valley Fever, referred to in 3.5.1 and initially thought to be anthrax, also affected numerous
humans.
In differential diagnosis of the severe forms, orbital cellulitis, dacrocystitis and deep tissue
infection of the neck should be considered in the case of severe anthrax lesions involving the
face, neck and anterior chest wall. Necrotising soft tissue infections, particularly group A
streptococcal infections and gas gangrene, and severe cellulitis due to staphylococci, should also
be considered in the differential diagnosis of severe forms of cutaneous anthrax.
4.4.1.2 Immunological tests
Subject to certain provisos, serology can, on occasion, be useful in supportive or retrospective
diagnosis of anthrax (see A.I.5). The practical aspects have been covered in 3.5.2.
Similarly, in the Russian sphere of influence, a skin test utilising AnthraxinT (Antiplague
Research Institute, Sovetskaya St., 13/15, Stavropol, 355106 Russian Federation; Fax: +7 8652
260312), first licensed in the former USSR in 1962, has become widely used for retrospective
diagnosis of human and animal anthrax and for vaccine evaluation (Shylakhov et al., 1997). This is
a commercially produced heat–stable protein–polysaccharide–nucleic acid complex, derived
from oedematous fluid of animals injected with the vaccine STI or the Zenkowsky strains of
B. anthracis. The test involves intradermal injection of 0.1 ml of Anthraxin and inspection after
15
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
24 h for erythema and induration at the site lasting for 48 hours after the injection. This delayed
type hypersensitivity is seen as reflecting anthrax cell mediated immunity and was reportedly able
to diagnose anthrax retrospectively some 31 years after primary infection in up to 72 % of cases
(Shlyakhov et al., 1997). It was used with success in a retrospective investigation of a series of
cases occurring in a spinning mill in Switzerland where synthetic fibres were combined with
goat hair from Pakistan (Pfisterer, 1990). The diagnostic reliability of Anthraxin, like Ascoli test
antigen (A.I.3.1), depends on the nature of anthrax rather than on the specificity of the antigens
involved.
4.4.1.3 Precautions
Surgical tools should be sterilized without delay after use, and dressings should be incinerated.
The wearing of surgical gloves by medical staff and orderlies is recommended but risks to these
staff are NOT high. Direct human–to–human transmission is exceedingly rare (see 4.3).
Vaccination of medical staff and orderlies is not necessary.
4.4.2 Gastrointestinal anthrax
There are two clinical forms of gastrointestinal anthrax which may present following ingestion
of B. anthracis in contaminated food or drink.
i)
Intestinal anthrax: Symptoms include nausea, vomiting, fever, abdominal pain,
haematemesis, bloody diarrhoea and massive ascites. Unless treatment commences
early enough, toxaemia and shock develop, followed by death. There is evidence
that mild, undiagnosed cases with recovery occur.
ii)
Oropharyngeal anthrax: The main clinical features are sore throat, dysphagia, fever,
regional lymphadenopathy in the neck and toxaemia. Even with treatment, the
mortality is about 50% (Doganay et al., 1986).
The suspicion of anthrax depends largely on awareness and alertness on the part of the
physician as to the patient’s history and to the likelihood that he/she had consumed
contaminated food or drink.
4.4.2.1 Confirmation of diagnosis. See 4.4.3.1
4.4.2.2 Differential diagnosis (gastrointestinal anthrax)
The differential diagnosis in intestinal anthrax includes food poisoning (in the early stages of
intestinal anthrax), acute abdomen due to other reasons, and haemhorragic gastroenteritis due
to other microorganisms, particularly necrotising enteritis due to Clostridium perfringens.
In the differential diagnosis of oropharyngeal anthrax, streptococcal pharyngitis, Vincent’s
angina, Ludwig’s angina, parapharyngeal abscess, and deep tissue infection of the neck should
be considered.
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Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
4.4.3 Pulmonary (inhalation) anthrax
Symptoms prior to the onset of the final hyperacute phase are non–specific and suspicion of
anthrax depends on the knowledge of the patient’s history. In probably the best–documented
set of five case reports of inhalation anthrax (Plotkin et al., 1960), the illnesses began insidiously
with mild fever, fatigue and malaise lasting one to several days. Headache, muscle aches, chills
and fever were recorded in all four patients with development of a cough in four and mild pain
in the chest in one. This mild initial phase was followed by the sudden development of
dyspnoea, cyanosis, disorientation with coma and death in four of the patients, in whom
treatment was unsuccessful. Death occurred within 24 hours of onset of the hyperacute phase.
4.4.3.1 Confirmation of diagnosis (pulmonary and intestinal anthrax)
As indicated, clinical diagnosis is dependent on a knowledge of the patient’s history; early
symptoms are non–specific and “flu–like” with mild upper respiratory tract signs in pulmonary
anthrax or resembling mild food poisoning in intestinal anthrax. In fact, in pulmonary anthrax,
the X–ray picture of the lung is very characteristic, with extremely enlarged mediastinal lymph
nodes. Frequently, however, confirmatory diagnosis of pulmonary or gastrointestinal anthrax
will usually take place after the patient has died or, if correct treatment is initiated early
enough, when he or she is well recovered.
The definitive diagnosis is made by the isolation of B. anthracis from sputum in pulmonary
anthrax and from vomitus, faeces and ascites in intestinal anthrax. Blood cultures may be
positive in either form of the disease.
Depending on the treatment administered and the stage the disease has reached at the
time of collection of specimens, smears stained for demonstration of the capsule (Appendix I)
may be positive, or the specimens may be positive by culture. B. anthracis may be visualized in
or isolated from sputum (pulmonary anthrax) or faeces (intestinal anthrax) but this cannot be
relied upon. Specialized laboratories may be able to demonstrate anthrax toxin in fluid
specimens (serum or oedematous fluid) or, in the case of patients who survive, anti–toxin and
anti–capsular antibodies may be demonstrable in convalescent sera (Appendix I [A.I.5]). The
Anthraxin hypersensitivity test referred to in 4.4.1.2 may also be applicable.
Death being due to the toxin, belated treatment can sterilize the blood and tissue fluids while
still not preventing death. If this sterilising effect has not occurred, the capsulated B. anthracis
may be visible in capsule–stained smears of these fluids and should be easily isolated from
them by bacteriological culture.
Where anthrax has not been suspected prior to postmortem, characteristic signs are dark
haemolysed unclotting blood, enlarged haemorrhagic spleen, petechial haemorrhages
throughout the organs, and a dark oedematous intestinal tract, ulcerated or with areas of
necrosis. In pneumonic anthrax, the mediastinal lymph nodes are always affected with
haemorrhagic necrotizing lymphadenitis. Nevertheless, it may be hard to differentiate between
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Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
pulmonary and intestinal anthrax at autopsy and the decision as to how the disease was
contracted may have to be based on the patient’s history.
4.4.4 Anthrax meningitis
Meningitis due to anthrax is a serious clinical development which may follow any of the other
three forms of anthrax. The case fatality rate is almost 100%; the clinical signs of meningitis with
intense inflammation of the meninges, markedly elevated CSF pressure and the appearance of
blood in the CSF (the meningitis of anthrax is a haemorrhagic meningitis) are followed rapidly
by loss of consciousness and death (Levy et al., 1981; Koshi et al., 1981; Lalitha et al., 1990;
George et al., 1994; Lalitha et al., 1996). Only a few instances of survival as a result of early
recognition of the problem and prompt treatment are on record (Khanne et al., 1989; Lalitha
et al., 1996).
Differential diagnosis should take into account acute meningitis of other bacterial aetiology. The
definitive diagnosis is obtained by visualisation of the capsulated bacilli in the CSF and/or by
culture.
4.4.5 Anthrax sepsis
Sepsis develops after the lymphohematogenous spread of B. anthracis from a primary lesion
(cutaneous, gastrointestinal or pulmonary). Clinical features are high fever, toxaemia and shock,
with death following in a short time.
In the differential diagnosis, sepsis due to other bacteria should be considered. Definitive
diagnosis is made by the isolation of B. anthracis from the primary lesion and from blood
cultures.
5
Pathogenesis and pathology
5.1 Toxin as the cause of death
The events occurring between entry of infecting B. anthracis into a lesion or uptake from the
lungs and death were covered in 3.4. At one time it was held that death from anthrax was due
to capillary blockage, hypoxia and depletion of nutrients by the exceedingly large numbers of
bacilli. Subsequently it was shown that death is attributable to a toxin (Keppie et al., 1955).
5.2 The virulence factors of B. anthracis
The capsule and the toxin complex are the two known virulence factors of B. anthracis.
The poly–D–glutamic acid capsule is presumed to act by protecting the bacterium from
phagocytosis.
The toxin complex, which consists of three synergistically acting proteins, Protective Antigen
(PA, 83kDa), Lethal Factor (LF, 87 kDa) and Oedema Factor (EF, 89 kDa), is produced during
the log phase of growth of B. anthracis. LF in combination with PA (lethal toxin) and EF in
18
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
combination with PA (oedema toxin) are now regarded as responsible for the characteristics
signs and symptoms of anthrax.
According to the currently accepted model, PA binds to receptors on the host’s cells and is
activated by a host protease which cleaves off a 20 kDa piece, thereby exposing a secondary
receptor site for which LF and EF compete to bind. The PA+LF or PA+EF are then internalized
and the LF and EF are released into the host cell cytosol.
EF is an adenylate cyclase which, by catalysing the abnormal production of cyclic–AMP
(cAMP), produces the altered water and ion movements that lead to the characteristic oedema
of anthrax. High intracellular cAMP concentrations are cytostatic but not lethal to host cells. EF
is known to impair neutrophil function and its role in anthrax infection may be to prevent
activation of the inflammatory process.
LF appears to be a calcium– and zinc–dependent metalloenzyme endopeptidase (Hammond
and Hanna, 1998). It has recently been shown (Duesbery et al., 1998) that it cleaves the amino
terminus of two mitogen–activated protein kinase kinases and thereby disrupts a pathway in
the eukaryotic cell concerned with regulating the activity of other molecules by attaching
phosphate groups to them. This signalling pathway is known to be involved in cell growth and
maturation; the manner in which its disruption leads to the known effects of LF has yet to be
elucidated. On the basis of mouse and tissue culture models, macrophages are a major target of
lethal toxin which is cytolytic in these. The initial response of sensitive macrophages to lethal
toxin is the synthesis of high levels of tumour necrosis factor and interleukin–1 cytokines and it
seems probable that death in anthrax results from a septic shock type mechanism resulting from
the release of these cytokines.
The endothelial cell linings of the capillary network may also be susceptible to lethal toxin and
the resulting histologically visible necrosis of lymphatic elements and blood vessel walls is
presumably responsible for systemic release of the bacilli and for the characteristic terminal
haemorrhage from the nose, mouth and anus of the victim (see Figures on the front cover).
The detailed nature and mode of action of the toxin has been more thoroughly reviewed in
various texts (Leppla, 1992; Quinn and Turnbull, 1998). Most of the recorded histopathological
studies on anthrax were done between 1945 and 1970; these are reviewed elsewhere (Quinn and
Turnbull, 1998).
6
Bacteriology
B. anthracis, the causative agent of anthrax, is a Gram positive, aerobic or facultatively
anaerobic, endospore–forming, rod–shaped bacterium approximately 4 µm by 1 µm, although
under the microscope, it frequently appears in chains of cells. In blood smears, smears of tissues
or lesion fluid from diagnostic specimens, these chains are two to a few cells in length (see
Figure B); in suspensions made from agar plate cultures, they can appear as endless strings of
cells – responsible for the characteristic tackiness of the colonies (see Figure D). Also
19
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
characteristic is the square–ended (“box–car” shaped) appearance traditionally associated with
B. anthracis vegetative cells, although this is not always very clear. In the presence of oxygen,
and towards the end of the exponential phase of growth, one ellipsoidal spore is formed in each
cell; this does not swell the sporangium and is generally situated centrally, sometimes sub–
terminally (see Figure A).
Under anaerobic conditions and in the presence of bicarbonate (HCO3), the vegetative cell
secretes a polypeptide (poly– (– D–glutamic acid) capsule. As covered in section 5, the capsule
is formed in vivo and is one of the two virulence factors of B. anthracis. It is also a primary
diagnostic aid (see 3.5 and 4.4.1, Appendix I [A.I.2] and Figure B).
6.1 Detection and isolation
In appropriate blood or tissue specimens collected within a few hours of death from animals
(see 3.5) or humans with anthrax, B. anthracis is readily detected in capsule–stained
(M’Fadyean–stained) smears and readily isolated in pure culture on blood or nutrient agar
plates. The same applies to smears of fluid from cutaneous lesions of humans prior to treatment
(see 4.4.1).
In old or decomposed animal specimens, or processed products from animals that have died of
anthrax, or in environmental samples, detection is likely to involve a search for relatively few
B. anthracis within a background flora of other bacteria, many of which will probably be other
Bacillus species, in particular, the closely–related B. cereus. In this case, selective techniques are
necessary. A procedure for the isolation of B. anthracis from such specimens is given in
Appendix I (A.I.1).
Such is the nature of the properties of B. anthracis that few agents which differentially select
between B. anthracis and other Bacillus species do so in favour of B. anthracis and those that do
only do so unconvincingly. Of the selective media that have been proposed, the most successful
is polymyxin–lysozyme–EDTA–thallous acetate (PLET) agar (Knisely, 1966), although care has
to be taken to prepare this correctly. As yet no selective enrichment broth system has been
devised for B. anthracis and, pending development of such a system, the sensitivity of in vitro
detection of B. anthracis by conventional means in environmental samples or specimens from
old or decomposed animals or from processed animal products is limited to approximately 5
cfu/g or /ml (Manchee et al., 1981).
As covered in Appendix I (A.I.1.4 and A.I.4), the most sensitive method for isolating the
organism is inoculation into a guinea pig or mouse. Although, in line with increasing aversion
to the use of animals for scientific tests, this should strictly be a last resort, there are times when
this may still be the necessary approach, for example, when confirming anthrax in individuals
or animals that have been treated with antibiotics, or in essential tests on environmental
samples that contain sporostatic chemicals.
20
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
Polymerase chain reaction (PCR) detection systems have been developed for B. anthracis
(Beyer et al. 1996; Patra et al. 1996; Sjöstedt et al. 1996; 1997), but it will probably be a few years
before they become fully reliable, adequately sensitive and robust, and generally available for
use in the non–specialist laboratory.
6.2 Identification and confirmation
With occasional exceptions, it is generally easy to identify B. anthracis and to distinguish it from
other Bacillus species, including B. cereus. For all practical purposes, an isolate with the
characteristic colonial morphology (Parry et al., 1983) on nutrient or blood agar (matt
appearance, fairly flat, similar to B. cereus but generally rather smaller, more tacky, white or
grey–white on blood agar, and often having curly tailing at the edges), and which is non–
haemolytic or only weakly haemolytic, non–motile, sensitive to the gamma–phage and
penicillin, and able to produce the capsule in blood or on anaerobic culture on bicarbonate
media is B. anthracis (see Figures D and E, and Appendix I [A.I.2]) .
The PCR is becoming more widely available as a means of confirming the presence of the
virulence factor (capsule and toxin) genes, and hence that an isolate is, or is not, virulent
B. anthracis. For routine purposes, primers to one of the toxin genes (usually the Protective
Antigen gene) and to one of the enzymes mediating capsule formation are adequate
(Appendix I [A.I.6] and Figure F). In laboratories not equipped for PCR tests, if doubt remains
at the end of the procedures given in Appendix I (A.I.1 and 2) as to the definitive identity of a
suspect B. anthracis isolate, inoculation into a mouse or guinea pig may necessary (Appendix I
[A.I.4]). However, as stated in 6.1, this should be a last resort procedure and confined to
situations where a definitive identity is essential.
Movement of infectious or contaminated materials from the site of origin to a diagnostic or
reference laboratory obviously presents a risk of spread of diseases if the materials
inadvertently escape into the environment during transit. Attention is drawn to the
recommendation of the United Nations Committee of Experts on Transport of Dangerous
Goods for packaging, labelling and documentation in relation to transport of infectious
specimens, detailed in other publications (WHO, 1997b), excerpts of which one is reported in
Appendix VIII.
7
Treatment
Prompt and timely antibiotic therapy usually results in dramatic recovery of the individual or
animal infected with anthrax. Almost all isolates of B. anthracis can be expected to be highly
sensitive to penicillin and, being cheap and readily available in most parts of the world, this
remains the basis of treatment schedules, particularly in animals and in humans in developing
countries. The organism is also sensitive to numerous other broad spectrum antibiotics; should
the use of penicillin be contraindicated, a wide range of alternative choices exist from among
21
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
the aminoglycosides, macrolides, quinolones and tetracyclines. Chloramphenicol is also a
satisfactory alternative.
We are only aware of four reports of the isolation of penicillin–resistant strains (Anon, 1996).
The molecular basis of susceptibility and resistance is complex (Lightfoot et al., 1990). It looks as
if it may prove to be the case that all B. anthracis strains carry the $–lactamase gene(s) on their
cromosomes but, apart from the exceptions mentioned, these are not expressed.
In pulmonary or gastrointestinal anthrax in humans, symptomatic treatment in an intensive
care unit in addition to antibiotic therapy may save the patient’s life; as referred to in 7.2.8, if
available, plasmaphoresed hyperimmune serum or gamma–globulin from vaccinated persons
may be considered in life–threatening situations.
7.1 Treatment of animals
7.1.1 General principles and approaches
Following the first incident of anthrax in a herd, the remaining animals should be moved
immediately from the field or area where the index case died and regularly checked at least
three times a day for two weeks for signs of illness (rapid breathing, elevated body
temperature) or of submandibular or other oedema. Any animal showing these signs should be
separated from the herd and given immediate treatment. Clinical experience has frequently
demonstrated that animals, especially cattle, will respond favourably to treatment even though
apparently in the terminal stages of anthrax. Even if they go on to die (death in anthrax results
from the effect of the toxin), the infecting load of B. anthracis will have been greatly reduced, if
not entirely eliminated, thereby significantly reducing the chance of subsequent transmission
from the carcass to other animals.
In endemic areas, or if there is concern that the outbreak may spread, the herd should be
vaccinated (see Appendix V). Further anthrax deaths usually cease within 8 to 14 days of
vaccination. Herd quarantine can be lifted 21 days after the last death. Decontamination of the
site(s) where the index case or other case(s) died should be carried out (see Section 8 and
Appendix III). [It should be remembered that vaccination and treatment should not be done
simultaneously; the treatment will prevent the live vaccine taking effect].
In certain countries, treatment is not permitted and slaughter policies are in place (7.1.2.4).
7.1.2 Specific procedures
7.1.2.1 Antimicrobial therapy in animals
The recommended procedure for treating animals showing clinical illness in which anthrax is
thought to be the likely or possible cause is immediate intravenous administration of sodium
benzylpenicillin as directed by the manufacturer’s instructions (usually in the range 12 000–
22 000 units per kg of body weight) followed 6–8 hours later by intramuscular injection of long
acting benethamine penicillin (manufacturers’ instructions usually recommend dose within
22
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
range 6000–12 000 units per kg of body weight) or other appropriate long–acting preparation
such as ClamoxylR (15 mg/kg), a long–acting preparation of amoxycillin. If long–acting
preparations are unavailable, procaine penicillin, (dose recommended by manufacturers is
usually 6000–12 000 units/kg) can be used for intramuscular injection but should be
administered again after 24 and 48 hours.
Streptomycin acts synergically with penicillin and penicillin/streptomycin mixtures are
available commercially. Recommended doses of streptomycin to be administered together with
penicillin intramuscularly are 5–10 mg per kg body weight in large animals and 25–100 mg per
kg body weight in small animals.
Veterinary experience in Britain is that, in contrast to advice frequently found in textbooks,
treatment with tetracyclines may not be fully effective.
Attention should be paid to manufacturers’ recommendations regarding precautions and
limitations of use and aspects relating to withdrawal periods after use in food animals.
Cost and availability are likely to be a major consideration in choice of treatment. For example,
combined penicillin and streptomycin treatment can be expected to cost twice as much as
penicillin alone.
7.1.2.2 Supportive therapy for animals
Symptomatic treatment may also be useful and a range of possible agents is available.
Supportive therapy with an agent such as flunixin (an analgesic with anti–inflammatory, anti–
pyretic and anti–endotoxic properties) may be advantageous although it will add significantly
to the cost of the therapy.
7.1.2.3 Hyperimmune serum therapy for animals
Hyperimmune serum has been used in the past for treating anthrax cases (Sterne, 1959) and it
was generally considered that homologous sera (e.g. serum prepared in cattle for bovine use,
etc.) were more effective than heterologous sera. Serum treatment of livestock is apparently still
practised in Russia.
The protective effect of immune serum administered therapeutically was demonstrated in
monkeys (Henderson et al., 1956). However, these were challenged by the inhalation route and,
once the effects of the immune serum wore off at about 20 days, the animals began to die of
anthrax from continued uptake into the lymphatics of spores that still remained in the lungs.
The possibility of relapse after the effect of this therapy has worn off should be borne in mind.
7.1.2.4 Countries prohibiting treatment in livestock
It should be noted that treatment of animals is forbidden in several countries. Veterinary
requirements in these countries are that, in a herd that has experienced a case of anthrax, other
animals showing signs of illness must be killed without spilling of blood or exsanguination and
the unopened carcass must be heat–treated in a rendering plant. Certain countries require the
23
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
slaughter of the entire herd following a case of anthrax; this draconian approach is unnecessary
and wasteful.
7.1.2.5 Therapy in wildlife
While the use of antibiotics for controlling anthrax in wildlife is, generally speaking, unlikely to
be feasible, it has reportedly been done with success in an outbreak in Tanzania where a single
treatment of roan and sable antelope and kudu, 50 animals in total, by direct darting, appeared
to arrest an outbreak (Dr SFH Jiwa, Faculty of Veterinary Medicine, Sokoine University of
Agriculture, P.O. Box 3110, Morogoro, Tanzania, personal communication).
7.2 Treatment of humans
7.2.1 Mild uncomplicated cases
In mild uncomplicated cases of cutaneous anthrax, penicillin V, 500 mg, taken orally every
6 hours for 5–7 days is adequate, but the treatment usually recommended is 3 to 7 days of
intramuscular procaine penicillin, 600 mg (1 million units), every 12–24 hours or intramuscular
benzylpenicillin (penicillin G), 250 000 units at 6–hourly intervals. Cutaneous lesions usually
become sterile within the first 24 hours of such regimens but, although early treatment will limit
the size of the lesion, it will not alter the evolutionary stages it must go through (Kobuch et al.,
1990).
7.2.2 Severe or potentially life–threatening cases
In severely affected patients or when pulmonary or gastrointestinal anthrax is suspected, the
initial treatment is penicillin G, 1200 mg (2 million units) per day by infusion or by slow
intravenous injection (<300 mg/min) every 4–6 hours until the patient’s temperature returns to
normal; at this point treatment should continue in the form of intramuscular procaine penicillin
administered as described above. Streptomycin, 1–2 g per day intramuscularly, may act
synergically with penicillin.
General measures for treatment of shock may be life saving since death is due, at least in part, to
toxin–induced shock. Intubation, tracheotomy or ventilatory support may be required in the
event of respiratory problems, and vasomotor support with dopamine may be necessary when
there is haemodynamic instability. Primary haematological, renal or liver function disorders are
not generally seen.
7.2.3 Supportive treatment for cutaneous anthrax
As covered in 5.2, the swelling seen in an anthrax infection is due to the action of oedema toxin
and there is very little associated inflammation. In theory, therefore, steroids should be of little
value. In practice, some reports indicate that these have been administered with evidence of
benefit but others (Kobuch et al., 1990) have concluded that they were ineffective, discontinuing
their use.
24
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
Early tracheotomy is advised if there is danger of tracheal obstruction; once oedema is extensive
it can be difficult to find the trachea at operation.
7.2.4 Alternatives to penicillin
In the event of allergy to penicillin, several antibiotics are effective alternatives, including
tetracyclines, chloramphenicol, gentamicin and erythromycin. Of the tetracycline family, tests in
animals have indicated doxyxycline is very effective and that the quinolone, ciprofloxacin may
also be suitable (Friedlander et al., 1991). Trimethoprim is not effective.
7.2.5 Adequate doses
In vitro tests (Lightfoot et al., 1990) have indicated that some strains of B. anthracis grown in the
presence of sub–inhibitory concentrations of flucloxacillin become resistant to penicillin and
amoxycillin either by induction of beta–lactamase or through some other, unidentified
mechanism. It is therefore important to use adequate doses of penicillin when this is being used
for treatment.
7.2.6 Duration of treatment
The appropriate duration of treatment is a subject for debate. B. anthracis cannot be isolated
from cutaneous lesions 24 to 48 hours after commencement of antibiotic therapy and Kobuch
et al (1990) could see no advantage to continuing treatment beyond 4 days. A report from
Ethiopia (Martin, 1975) records that 100 patients with cutaneous anthrax were treated with a
single intramuscular dose of procaine penicillin, 600 000 units, and 99 of these were sent home
with the invitation to return if complications occurred. Only 5 returned on account of further
developments. Physicians tend to continue treatment for 7 to 14 days, but it needs to be kept in
mind that the lesion will continue to progress through its cycle of development and resolution
regardless of the elimination of the infecting B. anthracis (7.2.1). Excessive treatment may be
wasteful and counterproductive.
In cases of inhalation anthrax, anthrax spores have been shown to persist for many weeks in the
lungs of monkeys infected experimentally by the aerosol route and kept on antibiotics
(Henderson et al., 1956; Friedlander et al., 1991); the animals succumbed to the disease once the
antibiotic treatment was stopped. Although this is unlikely to occur in the natural situation, in
cases where known or suspected inhalation of anthrax spores has taken place, especially if this
was likely to have been substantial, it may be prudent to consider the administration of a non–
living vaccine simultaneously with treatment. The treatment should be continued for about
6 weeks to allow for development of adequate vaccine–induced immunity. (The issue of
simultaneous treatment and vaccination in countries that administer live vaccines to humans is
discussed elsewhere (Pomerantsev et al., 1996; Stepanov et al., 1996).
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Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
7.2.7 Treatment of anthrax meningoencephalitis
Lessons from the few recorded instances of survival in cases of anthrax meningoencephalitis
suggest that penicillin (2 million units of crystalline penicillin intravenously every 2 hours
initially) remains the antibiotic of choice because it diffuses into the CSF through highly
inflamed meninges. Chloramphenicol (1 g intravenously every 4 hours) is a suitable alternative
for hypersensitive patients. The effectiveness of newer antibiotics, known to achieve a
satisfactory degree of penetration into the CSF, has not been determined.
Essential supportive therapy includes the early institution of anticerebral oedema measures,
such as 100 ml of 20% mannitol intravenously every 8 hours and hydrocortisone, 100 mg every
6 hours. Useful references to anthrax meningoencephalitis are given in 4.4.4.
7.2.8 Hyperimmune serum therapy
The use of anti–anthrax serum was abandoned years ago in most western countries as of
negligible value, but it is apparently still done in China (Dong, 1990) and the Russian
Federation (Anon, 1996). With the availability of modern plasmaphoresis techniques, specific
human gamma–globulin from vaccinated individuals could well be of life–saving value in an
emergency. The disease is readily responsive to early antibiotic treatment but, as has been
pointed out before, death is due to the toxin and delayed treatment may sterilize the blood and
tissues while not preventing death. Thus, if initiated after 24–36 hours following clinical onset,
antibiotic treatment may fail to save life in pulmonary, intestinal or complicated cutaneous
cases. In these cases, specific gamma–globulin containing anti–toxin antibodies may be life–
saving.
7.2.9 Recurrence after treatment
Recurrence of disease on termination of treatment is very rare but convalescent cases should
remain under observation for at least a week after treatment has ceased.
8
Control
Control measures are aimed at breaking the cycle of infection depicted in Figure 3. Each of the
following actions must be rigorously implemented.
•
correct disposal of anthrax carcasses (point X)
•
correct disinfection, decontamination and disposal of contaminated materials
(point Y)
•
vaccination of exposed susceptible animals (point Z1) and humans in at–risk occupations
(point Z2).
26
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
8.1 Disposal of anthrax carcasses (point X in Figure 3)
Because sporulation of B. anthracis requires oxygen and therefore does not occur inside a closed
carcass, regulations in most countries forbid postmortem examination of animals when anthrax
is suspected. Most, if not all, the vegetative B. anthracis cells in the carcass are killed in a few
days by putrefactive processes. Nevertheless, with the characteristic terminal serosanguinous
exudates from the nose, mouth and anus, some organisms may escape and sporulate. The
precise length of time after which no viable B. anthracis remain within the carcass is
unpredictable but depends greatly on climatic conditions, particularly temperature.
Figure 3. (see Figure 1 [section 2.1] for further notes).
8.1.1 Alternatives
In most countries, the preferred method of disposal of an anthrax carcass is incineration,
although, in some countries, it is considered that the best approach to the disposal of anthrax
carcasses is an effective controlled heat–treatment or “rendering”. Where neither of these
approaches is possible, for example due to lack of fuel, burial is the remaining best alternative.
In some developing country situations, however burial, incineration or rendering may not be
feasible. The last resort in such situations is to leave the carcass unmoved and adequately
closed off from other animals, particularly scavengers, or people. The carcass should be fenced
27
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
off and covered using branches of trees, corrugated iron or any other available materials, and
hazard signs should be posted around the site. B. anthracis within the animal carcass does not
sporulate and is inactivated by the putrefactive process in a few days. However, environmental
contamination due to bloody exudate escaping from the mouth, nose and anus of the death
animals may still occur. The resulting environmental contamination could be minimised by
scorching the site with fire, after the carcass has effectively putrefies, though this may be many
months later. Clearly, this is far less satisfactory than incineration, rendering or burial which
should be carried out as the preferred option unless absolutely impossible.
8.1.2 Burial
Periodic reports of viable anthrax spores at burial sites of animals which died many years
previously have testified to the unreliability of burial procedures for long term control of the
disease. Disturbance of such sites, for example by ploughing, or laying drainage, brings the
spores to the surface; even without site disturbance, spores can work their way up to the soil
surface. In either case, this may result in new livestock cases.
Further disadvantages to burial sites are that scavengers may dig down to reach the carcass,
and, in dry, dusty areas, the digging process can spread the contaminated soil extensively. In
Wood Buffalo National Park, Canada, where burials of bison that had died of anthrax were
carried out in the 1960s, the raised burial mounds became excavation sites for foxes and wolves
building their dens and nesting sites for ants (D.C. Dragon, Department of Medical
Microbiology and Immunology, University of Alberta, Edmonton, Canada, personal
communication).
In summary, burial should be discouraged in favour of incineration or rendering where
possible.
8.1.3 Incineration
Guidelines on incineration procedures are given in Appendix III (A.III.3). Ideally, the soil
surrounding and under the carcass, particularly around the nasal and anal regions, should be
decontaminated (see 8.3.8) and then incinerated with the carcass.
Incineration must be done with appropriate care to ensure complete burning from beneath.
Usually this involves raising the carcass off the ground before the process is started (see
Appendix III [A.III.3]). Commercial incinerators designed to ensure this are available (see
Figures G–J). It must be appreciated that spores that have soaked into the soil may survive the
incineration process although isolation of B. anthracis from incineration sites is rare. The down–
directed blow–torch shown in Figures K and L (see also Appendix III [A.III.3.3]), illustrates an
alternative incineration procedure which ensures severe scorching of the soil to several
centimetres of depth.
28
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
Comments are occasionally encountered opposing incineration on the basis that anthrax spores
may survive the fire and become aerosolized in the updraft. Circumstantial evidence does not
support the contention that incineration of anthrax carcasses results in the transmission of
anthrax in this manner.
Blenkharn and Oakland (1989) were able to isolate Gram positive bacteria, predominantly
Bacillus species, from the base of the exhaust stack of a hospital waste incinerator with design–
specified operating temperatures of 800 °C and 1000 °C in the primary and secondary chambers
respectively, thereby demonstrating that there is no room for complacency. However, numbers
were very low, averaging 56 cfu per cubic metre (range 0–400 cfu per cubic metre) and would
be subject to rapid further dilution on leaving the chimney. A badly constructed pyre producing
smoke with little or no flame might result in a higher survival rate of organisms collected by the
updraft. However, as discussed in relation to windborne spores from anthrax carcass sites
(Turnbull et al., 1998), the dilution effect on anthrax spores dispersed in airborne form from a
carcass is such that, for even the most susceptible animal species, the risks of infectious doses
arising are absolutely minimal.
A further consideration is that the anthrax organisms in an unopened carcass are in the
vegetative form (see 8.1) and are highly susceptible to heat and other adverse conditions. The
spores will be confined to where the blood has been shed through the mouth, nose or anus, and
will mostly be in the soil beneath these points. Consequently, relatively few spore forms will
enter the fire and updraft; vegetative forms are very unlikely to survive.
8.1.4 Rendering
Rendering is essentially a cooking process which results in sterilisation of raw materials of
animal origin such that parts of carcasses may be utilized safely for subsequent commercial
purposes.
There are a number of variations of the rendering process, broadly divided into batch processes
and continuous processes. In general, the raw materials are finely chopped and then passed into
a steam–heated chamber and subjected to temperatures ranging from 100 oC to 150 oC for 10–60
minutes (this does not include the time taken to bring the material to the peak temperature or
the subsequent cooling period time).
The rendering procedure involves correct performance at each of three stages: collection,
transport and treatment of the carcass (Riedinger et al., 1975; Riedinger, 1980; Strauch, 1991).
These should be supervised by veterinary authorities. The rendering plant must be properly
divided into "dirty" and "clean" areas. The dirty side must be suitably equipped for disinfection
of the transport vehicles and other equipment involved. Wastewater from the dirty side must be
collected and autoclaved. Before the heat treatment, carcasses have to be broken down in a
closed system into pieces not larger than 10 cm3. Controlled heat treatment is then carried out
with temperature, pressure and time of sterilisation recorded.
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Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
The level of hygiene being maintained in the clean side of the rendering plant should be
monitored at least twice yearly by the veterinary authorities.
8.2 Infection control in the management of human anthrax cases
As said in 4.3, the risk of human–to–human transmission is not a serious one given that sensible
precautions are taken. For example, cutaneous anthrax lesions should be dressed for the first
24–48 hours after treatment; disposable gloves should be worn, or gloves that can be sterilized,
while applying the dressing and during subsequent disposal of specimens or sterilisation of
materials and equipment (see 8.3.9).
Prophylactic antibiotics and vaccination are not necessary for health workers or family contacts,
though the latter should be instructed to consult their physicians in the event of suspicious
signs or lesions.
In fatal cases, postmortem should be discouraged; cremation is preferable to burial where local
custom permits. It is advisable for the body to be placed in an impervious body bag for
transport from the place of death and preferably the body should not be extracted from the bag.
Where only burial is permitted, the bagged body should be placed in a hermetically sealed
coffin and buried without re–opening. Useful guidelines are available elsewhere (Healing et al.,
1995; Young and Healing, 1995).
Bedding and contaminated materials should be bagged and incinerated, autoclaved or
fumigated as appropriate. Whether room fumigation is necessary will depend on the perceived
level of contamination in the room where the patient died (see 8.2.3).
8.3 Disinfection, decontamination and disposal of
infected/contaminated material (site Y in Figure 3)
In addition to helping break the local cycle of anthrax infection, disinfection, decontamination
and correct disposal of infected/contaminated material are of considerable importance in
preventing international transmission of anthrax. In non–endemic countries, risks arise largely
from animal products — wool, hair, hides, bone, etc. — imported from endemic regions.
Regulations regarding importation of untreated animal products vary from country to country
but several importing countries take the view that the financial costs that would be incurred
from legislating for the sterilisation of such imports would be disproportionate to the benefits.
In many countries, some or all of the following requirements are in place to limit the risks of
importation or dissemination of products contaminated with anthrax spores:
•
products must be accompanied by a certificate signed by a veterinary official in the
country of export certifying that they derive from anthrax–free sources (see Appendix IV)
•
products regarded as having a high chance of containing anthrax spores are subject to
some form of monitoring or control
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Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
•
finished or raw materials from certain countries may be subject to import restrictions
•
finished or raw materials from certain countries may have to undergo a general
sporicidal treatment before processing or distribution.
In the case of hides and skins (where no sterilisation procedure that does not damage the
materials has been devised), the exporting countries nowadays often require the initial
processing stages to be carried out before export for financial benefit. This has meant that far
fewer anthrax–contaminated hides and skins now reach non–endemic countries than was the
case a few years ago.
Sections 8.3.1–12 aim to supply information by which each country can formulate its own
control programme according to its particular circumstances. However, it is clear that long–
term global control depends almost entirely on the application of appropriate measures to
prevent the disease among livestock in enzootic exporting countries. Ideally, national policies
should ensure that materials known to be contaminated with anthrax spores are appropriately
disposed of and are not included in any industrial process. The procedures in sections 8.3.10–12
are essentially designed to protect workers and the environment in situations where
inadvertently contaminated materials may enter the processing line.
8.3.1 Decontamination of manure, dung, bedding, unused feed, etc.
Where possible, anthrax–contaminated materials to be disposed of, such as bedding, feedstuffs,
manure, etc, should be incinerated or autoclaved (121+1 oC core temperature for 30 min).
Immersion in 4% formaldehyde (10% formalin) for >12 hours is an alternative but full
penetration of the fluids must be ensured. (Caution: avoid skin contact with formaldehyde solutions
or inhalation of formaldehyde vapour).
8.3.2 Disinfection of surfaces in rooms, animal houses, vehicles, etc.
For general principles on disinfection and sporicidal disinfecting agents, see Appendix III.
Disinfection of contaminated surfaces involves a three–step approach aimed at (i) preliminary
disinfection, (ii) cleaning, and (iii) final disinfection. Effective disinfection of spores can be
extremely difficult and, under some circumstances, it may not be possible to achieve this
completely. It is important, therefore, to act promptly following cases of anthrax in order to
prevent, as far as possible, the release and sporulation of vegetative cells from the dying or dead
animal.
Stage 1: Preliminary disinfection
One of the following disinfectants may be used in amounts of 1–1.5 litres per square metre for
an exposure time of 2 hours (Caution: avoid skin contact with the disinfectants listed below or
inhalation of their vapours):
•
10% formaldehyde (approximately 30% formalin), or
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Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
•
4% glutaraldehyde (pH 8.0–8.5)
A high pressure cleaner may be used but, to avoid spreading the contamination, the pressure
should not exceed 10 bar.
Stage 2: Cleaning
Where practical, cleaning of all surfaces should be done by straightforward washing and
scrubbing using ample hot water. The operator should wear protective clothing, face and hands
included. Cleaning should be continued till the original colours and surfaces are restored and
the waste water is free of dirt particles. At the end of the process, residual water should be
removed and the surfaces dried. High pressure cleaners are again discouraged because of the
greater potential to spread the contamination through aerosols. If used, however, the water jet
should be applied at a pressure of 80–100 bar delivering 13–15 litres/ minute.
Stage 3: Final disinfection
For final disinfection, one of the following disinfectants should be applied at a rate of 0.4 litres
per square metre for an exposure time of at least 2 hours:
•
10% formaldehyde (approximately 30% formalin)
•
4% glutaraldehyde (pH 8.0–8.5)
•
3% hydrogen peroxide
•
1% peracetic acid.
Hydrogen peroxide and peracetic acid are not appropriate if blood is present. When using
glutaraldehyde, hydrogen peroxide or peracetic acid, the surface should be treated twice with
an interval of at least one hour between applications. Formaldehyde and glutaraldehyde should
not be used at temperatures below 10 oC. After the final disinfection, closed spaces such as
rooms or animal houses should be well ventilated before re–commissioning.
The effectiveness of the disinfection procedure cannot be assumed and attempts should be
made to confirm it has been adequate by means of swabs and culture.
In the case of surfaces within a room, it may be considered appropriate to finish the disinfection
process by fumigating the room itself as described in 8.3.3.
8.3.3 Fumigation of closed spaces – cabinets, rooms, etc.
Safety cabinets should be treated as fumigation chambers and fumigated according to the
procedure given in paragraph 2 of 8.3.9.
Rooms where surfaces cannot be cleared before decontamination and disinfection, such as
laboratories, can be fumigated by boiling off (for rooms up to 25–30 m3) 4 litres of water
containing 400 ml of concentrated formalin (37% w/v formaldehyde) in an electric kettle (fitted
with a timing or other device to cut off the electricity when the fluid level has reached the
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Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
element) and leaving overnight (or no less than 4 hours from the point in time when the boiling
process has been completed) before venting. Room temperature should be >15oC.
Before fumigation commences, all windows, doors and other vents to the outside should be
sealed with heavy adhesive tape. Hazard warning notices should be posted on the door(s) and,
if appropriate, windows. Proper chemical respirators should be on hand and at least one
nitrocellulose disk or filter paper which has, beforehand, been dipped in a spore suspension
(preferably an accepted standard, such as B. subtilis var globigii [NCTC 10073] or B. cereus
[ATCC 12826], but failing the availability of these, the spores of the Sterne vaccine strain (34F2)
of B. anthracis would do) and dried should be placed at some point in the room distant from the
kettle. (Caution: avoid skin contact with formaldehyde solution or inhalation of formaldehyde vapour).
At the end of the fumigation, the spore disk(s) should be retrieved into a sterile petri dish and
the windows or vents to the outside air should be opened up. A chemical respirator should be used
for this. A fan, or fans, assist the extraction. Doors into the room should be kept closed and other
personnel prevented from passing near or through them until venting is complete. If a
formaldehyde meter is available, venting should not be considered complete until levels of less
than 2 ppm have been reached. In the absence of a meter, the odour of formaldehyde should
have become almost undetectable before entry into the room without a respirator is allowed.
The effectiveness of the fumigation procedure is checked by placing the spore disk(s) on plates
of nutrient agar containing 0.1% histidine (final concentration and added as a filter–sterilized
solution after the agar has been autoclaved and cooled to 50 oC). After overnight incubation at
37 oC, if fumigation was properly effective, the disks should show no bacterial growth.
For health and environmental protection reasons, there are moves to replace formalin with
hydrogen peroxide vapour as the recommended general purpose microbiological fumigant.
Indeed, the use of formalin is being increasingly forbidden in some countries. However, the
equipment needed for hydrogen peroxide fumigation is, at present, cumbersome, elaborate and
expensive and is not universally available. It would not lend itself to routine fumigation of
safety cabinets after every use. This section will be updated when the appropriate progress has
been made.
8.3.4 In the laboratory – spills, splashes, accidents
Chlorine solutions. Commercially–prepared hypochlorite frequently takes the form of stock
solutions having approximately 10% available chlorine (100 000 ppm). Thus, what is familiarly
referred to in laboratories as "10% hypochlorite solutions" is a 1:10 dilution of the stock solution
containing 10 000 ppm available chlorine. If solid precursors of hypochlorous acid is available,
stock solutions containing 100 000 ppm available chlorine should be prepared and the required
dilutions made from this.
Chlorine solutions are not highly stable and stock solutions should be titrated periodically to
ensure that the correct level of available chlorine is present (see Appendix III (A.III.2.1.4)). Since
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Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
stability is affected by concentration (and also by temperature and pH), subsequent dilutions
should be made only as needed and these solutions should be changed frequently (at least
weekly). It should be remembered that chlorine solutions corrode metals and perish rubber and
that chlorine is rapidly neutralized by organic materials, including wood (as in wooden
benches), soil, or specimens of blood or tissues.
Simple chlorine solutions are slow to kill spores (Jones and Turnbull, 1996). The sporicidal rate
can be increased by using 50% methanol or ethanol to make the dilutions of the stock solution.
Rapid turnover items such as pipettes, disposable loops, microscope slides, sampling spoons,
etc., should be immersed overnight in hypochlorite solutions with 10 000 ppm available
chlorine and then transferred to an autoclave bin or bag for autoclaving, or to a bag for
incineration.
Benches should be wiped down after use with hypochlorite solutions containing 10 000 ppm
available chlorine. Because of their neutralising effect on chlorine, wooden benches should be
replaced by more suitable materials or covered with plastic or laminated sheeting, or with a
proprietary covering designed for the purpose, such as BenchcoteT (Whatman International Ltd,
Maidstone, UK).
Spills and splashes on surfaces. Some thought must be given to the nature of the material
spilled. For example, freshly growing B. anthracis cultures will have few, if any, spores and
these will be incompletely dormant and more susceptible to disinfection procedures than, at the
opposite extreme, purposely prepared spore suspensions.
In general, spills and splashes on floor, bench or apparatus should be flooded with hypochlorite
solution containing 10 000 ppm available chlorine and vertical surfaces should be washed or
wiped down thoroughly with cloths soaked in this solution (the operator should wear gloves and
safety spectacles while doing this). Spills and splashes from fresh cultures can be mopped up with
towelling after 5 minutes; the towelling should be placed in an autoclave bin or bag and
autoclaved or in a bag for incineration. Spills or splashes of spore suspensions should be left for
30–60 minutes before mopping up unless the area can be sealed off and fumigated, in which
case mopping up can be done after a few minutes and fumigation carried out immediately as in
8.3.3.
An alternative approach is to cover the contaminated area with absorbent material and wet this
with an excess of disinfectant. Solutions of 10% formalin, 4% glutaraldehyde or 1% peracetic
acid may be more appropriate than hypochlorite, but the choice must be weighed against the
greater personal protection needed when using these. HAZ–TAB disinfectant granules (Guest
Medical, Edenbridge, Kent TN8 6EW, UK) are commercially prepared for this purpose.
Spills and splashes on clothing. Laboratory gowns (surgical type) are the best type of
overclothes to wear in laboratories working with B. anthracis and disposable versions are
available. In their absence, a plastic apron should be worn over the laboratory coat.
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Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
Contaminated gowns/aprons/coats should be removed immediately and placed in autoclave
bins or bags and autoclaved (disposable gowns can be incinerated). Personal clothing that may
still be contaminated — shoes, socks/stockings/upper garments if sleeves or collars are
contaminated — should be removed as soon as possible and fumigated as in 8.3.3.
Spills and splashes on skin, in eyes. For skin contamination the area should be bathed in
hypochlorite solution containing 5000 ppm available chlorine for one minute and then washed
thoroughly with soap and water. Where the skin is broken (including needle–stick punctures),
bleeding should be encouraged and the injury washed with copious amounts of water. The
current Occupational Health wisdom is that immersing punctured skin in hypochlorite
solutions does more harm than good. The appropriate medical officer should be informed and
the affected person kept under observation for at least a week.
For splashes in the eye, the eye must be flushed out with copious quantities of water
immediately. Avoid rubbing the eye. The appropriate medical officer should be informed and
the affected person kept under observation for at least a week.
Contamination in the mouth. At the outset laboratory workers should be reminded that mouth
pipetting in a microbiology laboratory is totally unacceptable. For contamination of the mouth
with known or possible anthrax organisms, the mouth contents should be immediately spat out
followed by a thorough mouth wash with hypochlorite solution containing 2000 ppm available
chlorine and several subsequent mouth washes with water. The appropriate physician should
again be informed and the affected person be kept under observation for a week.
8.3.5 Decontamination of liquid manure
Slurry from pigs and cattle suffering outbreaks of anthrax should be disinfected with
formaldehyde added with thorough stirring to a final concentration of 2–4% depending on the
content of dry matter. This is approximately equivalent to 50–100 kg of formalin (37%
formaldehyde solution) per m3 of slurry. The mixture should be left a minimum of 4 days with
stirring for at least one hour each day before being removed elsewhere. (Caution: avoid skin
contact with formaldehyde solution or inhalation of formaldehyde vapour).
The formalin degrades naturally and the treated slurry can be spread on uncultivated land and
ploughed in or otherwise buried.
8.3.6 Decontamination of sewage sludge
Sewage sludge containing effluents from tanneries may contain anthrax spores. Dewatered
sewage sludge up to a dry matter content of 8% should be disinfected with 5% formaldehyde
for 10 hours or 3% peracetic acid for 30 minutes. The disinfection process is not affected by the
use of lime or polyelectrolytes for dewatering the sludge (Lindner et al., 1987). (Caution: avoid
skin contact with formaldehyde or peracetic acid solutions or inhalation of their vapours).
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Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
8.3.7 Treatment of water
It is difficult to give general advice on treatment of water. The approach chosen depends on
what type of body of water is to be treated, the likely extent of the anthrax spore contamination,
what volumes are involved and where the water is to go and what it may be used for after
treatment. However, the choices are much the same as with other materials covered within this
section 8.3.
Autoclaving is the surest way of killing spores but is only applicable to fairly small volumes of
water.
Treatment with formaldehyde (5–10% final concentration) for at least 10 hours is feasible for
volumes up to about 100 000 litres, as may result from industrial wastes, but holding tanks must
be available and methods of neutralisation and discharge without danger to the environment
must be established. Cost is a major factor in this approach also.
The merits of chlorination are debatable; the levels of chlorine necessary to ensure effective
killing of spores may be hard to attain in large volumes and, if the body of water is on open
ground, it is likely to contain organic matter which rapidly neutralizes the chlorine.
Filtration, as for water treatment, is probably effective as far as the emerging water is concerned
but leaves unsolved the problem of contaminated filter beds.
In general, each situation must be considered on an individual basis and the best solution
worked out for the particular circumstances that exist.
8.3.8 Treatment of soil
If possible, soil at the site of an anthrax carcass should be removed up to a depth of 20 cm and
incinerated or heat treated (121oC throughout for 20 min). If this is not possible, it should be
disinfected with 5% formaldehyde solution at 50 litre per m2. Where it is necessary to
decontaminate soil to greater depths, such as burial sites of anthrax carcasses, 5% formaldehyde
solution should be injected below the soil surface at a rate of 30 ml for every 10 cm of depth at
0.5 m horizontal intervals across the contaminated area. (Caution: avoid skin contact with
formaldehyde solution or inhalation of the vapour).
It is sometimes not possible to achieve sufficient penetration of even small clods of soil by
formaldehyde or other sporicide solutions to result in complete kill of anthrax spores (Turnbull
et al., 1996), especially in the case of water–saturated or heavy soils. Decontamination failure can
result when attempting chemical disinfection and the effectiveness of any such attempt should
be checked by subsequent culture.
The decision on the best approach to making a contaminated site safe depends substantially on
what the site is to be used for in the future. Where it is not feasible to incinerate or chemically
decontaminate the soil or to remove it to an incinerator, the alternative is to close or seal off the
site. Covering with concrete or tarmac for, say, a car park, is an alternative used in
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Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
industrialized countries; planting with thorny bushes surrounded by a secure fence can be an
aesthetic approach.
Further guidelines are supplied elsewhere (Turnbull, 1996).
8.3.9 Other materials – clothing, tools, etc.
Where possible, contaminated materials should be incinerated or autoclaved at 121 °C for
30 minutes. In the case of non–disposable items, such as clothing, boots, tools, etc., excess dirt
should be scraped off into incineration or autoclave bags and the items themselves should be
soaked overnight (at least 8 hours) in 4% formaldehyde solution or 2% glutaraldehyde (pH 8.0–
8.5). (Caution: avoid skin contact with formaldehyde or glutaraldehyde solutions or inhalation of their
vapours).
Materials and equipment that cannot be autoclaved, boiled or immersed in formalin or other
solutions may be fumigated in fumigation chambers of 1 to 3 m3 using 15–50 ml of 37%
formaldehyde solution diluted 2–3–fold with water and boiled off with an electric element. The
temperature should be ambient (>18oC) and exposure time overnight (at least 4 hours, but
preferably more than 12 hours, especially if contamination is likely to be heavy or penetration
by the fumigant into the material being fumigated is likely to be slow). The chamber should be
properly constructed, airtight with a system of venting to the outside away from places of
human or animal movement at the end of the fumigation procedure. The relative humidity
within the chamber should be >90% during the fumigation procedure.
Ethylene oxide may be used as an alternative to formaldehyde if the facilities are available. The
gas is acutely toxic at concentrations of >50 ppm and can cause skin burns and blistering; it is
also explosive under alkaline conditions or if exposed to certain other chemicals. Although
highly effective, it is really only to be recommended where the correct facilities and expertise in
its use are available.
8.3.10 Decontamination of wool and hair
Disinfection stations exist in a number of countries which import wool, hair or bristles from
endemic regions and the names and addresses of these can be obtained from the relevant
veterinary authorities. One established disinfecting protocol is the Duckering process. This
involves five stages, each of 10 min duration at 40.5 oC: (i) immersion in 0.25–0.3% soda liquor;
(ii) immersion in soap liquor; (iii), (iv) two immersions in 2% formaldehyde solution; and
(v) rinsing in water. The wool or hair is finally dried in hot air and baled.
In countries where irradiation facilities are available, the preferred approach is to test samples
of wool and hair from a consignment and, if positive for B. anthracis, to sterilize the
consignment by irradiation. The dose needed to guarantee freedom from viable spores in a
contaminated lot is very high; the D100 in spore suspensions of 108 to 1010 per ml have been
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Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
found to exceed 40 kGy (Bowen et al., 1996). Calculations of exposure times need to take into
account the size and density of the bales being irradiated.
8.3.11 Hides and skins
No hazard need be expected in situations where hides come from properly supervised
slaughtering. Dry hides of uncertain origin within enzootic countries must, on the other hand,
be regarded as being of high risk in terms of anthrax. Where possible these should be
decontaminated by formaldehyde or ethylene oxide fumigation or by irradiation prior to
processing. It is considered in some quarters, however, that no pre–processing disinfection
protocol has been devised for hides and skins that does not damage them (Anon, 1959).
However, the dehairing stage, which involves sodium sulphide liming with a mixture of
sodium sulphide and calcium hydroxide, exposes the skins to a significant level of sodium
hydroxide at high pH which probably kills any B. anthracis spores present (Robertson, 1948;
Lindner and Böhm 1985).
Control processes in tanneries must, therefore, be primarily targeted at stages before dehairing,
particularly dust control and treatment of effluent from initial washing and rehydrating stages.
In tanneries processing raw hides from anthrax endemic areas, these effluents should be treated
with 5% formaldehyde (starting level) for 10 hours, with adequate time being allowed for
natural degrading of the formaldehyde, before discharging to sewerage. Peracetic acid (3%) for
>30 minutes is an alternative but more expensive treatment.
Precautions should be taken to avoid cross–contamination of hides and skins pre– and post–
treatment through appropriate controls on movement of personnel, equipment and the hides
themselves (Appendix IV).
8.3.12 Bone, hoof and horn
Feed ingredients of bone, hoof and horn origin imported from endemic countries are still the
cause of incidents among livestock in non–endemic importing countries. Similarly, bonemeal in
fertilizers is periodically suspected of being the source of anthrax infection in humans and
animals. However, in many developed countries, anthrax is becoming very infrequent. It is
considered in these countries that mandatory requirements for sterilisation of these types of
products for international commerce would raise the costs of these products disproportionately
to the human and animal health risks involved. Consequently few countries have statutory
requirements of this nature. However, some manufacturers consider it standard good practice
to sterilize bonemeal before placing it on the market and this is certainly to be encouraged.
Similarly it should be a reasonable policy aim in any country to collect and process separately
those raw bone, hoof and horn products obtained from regular and supervised slaughtering
and those obtained from sources of uncertain origin which present a higher risk in terms of
anthrax.
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Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
Long–term control will be dependent on improved and effective control measures in the
exporting countries. In the interim, control must depend on close adherence to the International
Zoo–Sanitary Code (Appendix IV).
8.4 Prophylaxis
8.4.1 The nature of protection in anthrax
Four decades of research have shown that protection against anthrax in the susceptible host is
dependent almost entirely on that host's immune response to a single antigen – the protective
antigen (PA) component of the anthrax toxin, a well–defined protein of molecular weight
83 kDa (see Section 5). Immune responses to the other two toxin components, the lethal and
oedema factors, may contribute to protection, but only in a relatively minor way (Ivins and
Welkos, 1988; Turnbull et al., 1988). No other antigens have been identified as contributory.
The effectiveness of both animal and human vaccines is dependent on the induction of anti–PA
antibodies. However, the immune response is complex and involves cellular immunity in some,
as yet, undefined manner; measurable anti–PA antibodies in the blood of an individual are not,
in themselves, a guarantee of protected status but, on the other hand, they must be there for the
individual to be protected (Ivins and Welkos, 1988; Turnbull et al., 1988; Ivins et al., 1990;
Turnbull et al., 1990). The enhanced efficacy of future vaccines over existing ones will be depend
on improved stimulation of the cellular immune response in parallel with the humoral response
to PA (see 8.4.4) (Quinn and Turnbull, 1998).
The mechanism by which an immune process based on anti–toxin immunity protects against a
disease characterized by rapid in vivo growth of the bacilli is not known yet. Neutralisation of
the lethal action of the lethal toxin on macrophages (see 5.2) is probably a major factor. It is also
possible that some action of the toxin which results in release of nutrients needed for
multiplication is inhibited.
8.4.2 Animal vaccines
Most anthrax vaccines in use around the world today utilize the toxigenic, non–capsulating
(pXO1+/pXO2–) B. anthracis strain 34F2 isolated in 1937 (Sterne, 1937). Earlier Pasteur–type
vaccines are still in use in at least one country (see Appendix V). The animal vaccines that use
strain 34F2 are essentially as originally formulated (Sterne, 1939) with approximately 107 spores
per ml suspended in 0.5% saponin in 50% glycerine–saline.
Animal vaccines against anthrax should be prepared in accordance with the Requirements for
Anthrax Spore Vaccine (Live – for Veterinary Use), Requirements for Biological Substances No. 13
(WHO, 1967) which points out the considerable differences in quality that can exist between
anthrax vaccines. The glycerine and saponin are important to vaccine performance. Vaccine
strains must be maintained carefully since uncapsulated B. anthracis variants may lose their
immunogenic powers on subculture (Sterne et al., 1939; Sterne, 1959). Since, in theory, the
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Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
vaccine is easy to prepare, many countries appear to be taking on their own manufacture; it is
important that careful quality control be exercised to avoid resurgences of anthrax because
inadequate vaccines are being used.
The protective effect of a single dose of strain 34F2 vaccine is said to last about 1 year (Sterne,
1939) and annual boosters are recommended for livestock in endemic areas. The duration of
the protection has never been systematically studied and this is an area of research that needs to
be done.
The 34F2 live spore vaccines appear to retain a degree of virulence for certain species such as
goats (Sterne, 1939; Cartwright et al., 1987) and llamas (Cartwright et al., 1987) in which they
must be used with caution (see Appendix V [A.V.1.1]).
8.4.3 Human vaccines
In China and in the countries of the former USSR, live spore vaccines are prepared for human
use (Appendix V). In most other countries, live spore vaccines are not licensed for use in
humans. In the UK and USA, non–living human vaccines developed respectively in the 1950s
and 1960s are available (Turnbull, 1991). The UK vaccine is an alum–precipitated cell–free
culture filtrate of strain 34F2 while the US vaccine is an aluminium hydroxide–adsorbed cell–
free culture filtrate of a non–capsulating, non–proteolytic derivative of bovine isolate V770.
The primary use of the human vaccines is for persons in at–risk occupations, particularly in
industries concerned with processing of animal products from endemic regions. The duration of
the protection afforded in man by vaccination is uncertain and, on empirical grounds, annual
boosters are recommended for workers in at–risk occupations. In certain circumstances, post–
exposure vaccination at the same time as administration of antibiotics may be appropriate (see
7.2.6).
Vaccination of humans who are not occupationally exposed to anthrax is inappropriate. For the
general public, control of the disease should be done through control in livestock.
8.4.4 Prospective new vaccines
As covered in 8.4.1, the prerequisite for protection against anthrax is an adequate humoral
immunity to the protective antigen (PA) combined with an appropriate cellular immune
response. This has to be taken into account in the design of new vaccines. While cellular
immune stimulation can be achieved by means of an effective adjuvant, the surest way of
ensuring this combined humoral and cellular response is to immunize with live vaccines. The
current animal vaccine (8.4.2) is a live vaccine and its greater efficacy over the non–living
human vaccines (8.4.3) in animal protection studies is attributed to its greater stimulation of
cellular immune responses in the recipients.
The live spore animal vaccine, however, has a number of disadvantages which need to be
overcome: (a) although greatly attenuated in comparison to normal virulent B. anthracis, the
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Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
34F2 vaccine strain retains a residual virulence (Welkos et al., 1986) and is responsible for
occasional losses among vaccinated animals; (b) its duration of effect is limited, and animals in
enzootic areas must be immunized annually; (c) it has to be administered parenterally, and
(d) efficacy and unwanted side effects can be greatly influenced by small faults in production.
Items (b) and (c) become important in developing countries where appropriate equipment and
manpower are limiting factors; item (d) has increasingly become a problem as "local"
production has tended to replace manufacture by a few major companies or centres.
When first introduced for administration to workers in at–risk occupations, human anthrax
vaccines were shown to be clearly associated with protection against the disease (Brachman
et al., 1962). That paper contains the only existing reference to anthrax in a fully vaccinated
person; since then, there have been no other such cases on record. However, protection tests in
animals have indicated that currently licensed human non–living vaccines (8.4.3) may have
limited efficacy and the protection they afford is of uncertain duration. Being essentially simple
culture filtrates, the vaccines are somewhat undefined and they are occasionally associated with
complaints of side effects. The case for the development of new vaccines rests on these issues.
The aims for prospective new vaccines are that they should be:
•
well–defined with well–characterized ingredients and mode of action
•
effective against challenge with any anthrax strain
•
safe, giving no dangerous side–effects in any species
•
long–lasting
•
easy to administer rapidly and by non–skilled persons
•
orally administrable, especially for livestock and at–risk wildlife species
•
cheap
•
environmentally acceptable.
Future vaccines are likely to take one of three forms:
(A) Subunit: non–living vaccines consisting of purified PA with an effective, well–defined
adjuvant. Recombinant PA from a B. subtilis construct could replace PA from
B. anthracis, thereby enabling manufacturers to produce the vaccine without having to
grow or handle B. anthracis or to separate PA from other toxin components. For
reasons of cost and practicality, subunit vaccines would only be appropriate for
human use. They would still need to be administered parenterally and would
continue to require regular boosters.
41
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
(B) Genetically manipulated
•
Deleted mutants: deletions from the gene for the PA have now been achieved (Singh et al.,
1989) such that this can no longer combine with lethal or oedema factors to form anthrax
toxin. A live vaccine based on a strain carrying this deletion would lack the residual
virulence associated with the existing live spore vaccine. Deletion of undesired toxin
factors might also eliminate adverse reactions.
•
Recombinant constructs: Constructs of B. subtilis, Salmonella typhimurium, baculovirus and
vaccinia virus carrying the PA gene have been made and shown to be capable of eliciting
protective immunity (Ivins et al., 1990; Iacono–Connors et al., 1991; Coulson et al., 1994).
Constructs of Lactobacillus species are being considered as potential oral vaccines.
•
DNA: The possibility that DNA coding for the appropriate protective antigens, or
subunits of those antigens, may replace the antigens themselves is true in the context of
anthrax vaccines as it is for a number of other diseases.
(C) Oral: The ideal vaccine is one which is only required in a single oral dose. The
constructs of Salmonella or Lactobacillus species referred to in the paragraph above
have been chosen for study with this in mind. Other approaches include the use of
microencapsulated PA, or modified PA, possibly with other immunogens or
adjuvants, or microencapsulated DNA for the appropriate antigens.
When choosing the appropriate design for an oral animal vaccine, it is important first to
consider the method by which the oral vaccine is to be administered. This must be such that
most, if not all, the target animals or species actually receive the vaccine at the correct dose
level. Livestock industries have extensive experience of oral vaccines (other than anthrax) for
domestic herds. The experience on the oral vaccination of foxes, other wild carnivores and dogs
against rabies may be used for designing a suitable vaccine and vaccine delivery system for
anthrax in wildlife (Schumacher and Meslin, 1998). Some consideration in this case also needs to
be given to the consequences if non–target animals or species take up the vaccine. Furthermore,
the vaccine must remain active sufficiently long to ensure it is effective at administration and
uptake by the proposed method, but it must not persist in such a way as to cause environmental
contamination. It is clear that producing the ideal oral vaccine for animals poses difficult
challenges.
8.5 Intersectoral issues: the question of eradication
As with any zoonosis, intersectoral cooperation is essential for effective control of anthrax.
Public health officials should be notified by the veterinary authorities in the event of outbreaks
in livestock so they become alert to the possibility of associated human cases. Likewise, medical
authorities should notify veterinary health officials when a human case is encountered (see 9.2).
42
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
Cooperation between livestock officials and wildlife managers in enzootic zones is more
complex. While the target of the former is eradication from his or her region, the disease is
regarded in game management areas as an integral part of natural population control
mechanisms. Action is seen as being necessary only when endangered species are at risk and is
usually targeted specifically at that species; beyond this, control actions are regarded as
constituting unwarranted interference with natural processes. In this instance, cooperation
needs to take the form of joint efforts to prevent mingling of susceptible livestock and wildlife
species, such as adequate and appropriate fencing, and to minimize other means by which
anthrax may be transmitted from wildlife to livestock.
Despite the well–known longevity of anthrax spores, decline in numbers does occur through
decay and/or dispersal at contaminated sites and eradication from livestock areas is feasible,
given sufficient time together with unremitting efficient application of the control procedures
covered in 8.1 to 8.4.
9
Surveillance
Surveillance, the systematic collection, collation and analysis of data and the dissemination of
the information to those who need to know in order that action may be taken, should provide
information throughout prevention, control and elimination/eradication. Control will not be
cost–effective or efficient if surveillance is not an integral part of the management of the
programme.
Most countries have laid down regulations for the reporting of infectious diseases including
anthrax. The problems that exist generally stem from failure to implement regulations, rather
than from their non–existence (see Appendix VII).
Clearly full implementation of the regulations depends on awareness and understanding of
these regulations and on cooperation by all involved. Those involved are likely to have diverse
standings within the community and include farmers/owners, community elders or members
of local authorities, local and regional human and veterinary health workers and officials, local
and regional clinical and veterinary laboratories, and officials of the ministries of health and
agriculture.
The surveillance scheme given below can be adapted to accommodate the local veterinary and
public health systems within any country. Routine cross–notification between the veterinary
and health sectors should be the rule, as well as close collaboration during epidemiological
investigations. However, well organised and reliable reporting systems of animal and human
cases still remain a distant goal for most developing countries.
A surprising number of countries use humans as sentinels as a result of differential quality and
availability of medical and veterinary diagnostic laboratories, and thereby missing the majority
of the livestock cases and misemphasising the impact of the disease and direction of ongoing
control programmes.
43
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
9.1 Public health surveillance of anthrax in humans
9.1.1 Specific objectives
Some of the specific objectives of a public health surveillance programme can be summarised as
follows:
(a) Identify the characteristics of the disease in the affected populations.
(b) Formulate prevention and control programmes for the human health and veterinary
sectors.
(c) Evaluate prevention and control activities through the monitoring of subsequent
incidence of the disease and carry out an evaluation of the cost–effectiveness of the
programme.
(d) Detect outbreaks and monitor changes in the epidemiological patterns of the disease,
modifying control activities appropriately.
(e) Ensure regular feedback of information to all groups involved.
9.1.2 Suggested case definition
The suggested case definition should be adapted to local needs and laboratory capabilities
available for confirmation of diagnosis (WHO, 1997c).
Clinical description
An illness with acute onset characterised by several clinical forms as described in detail in
section 4.4. These could be summarised in a concise case definition for surveillance purposes as
follows:
(a) Localised form:
•
cutaneous: skin lesion evolving over 2 to 6 days from a papular through a vesicular stage,
to a depressed black eschar invariably accompanied by oedema that may be mild to
extensive.
(b) systemic forms:
•
gastrointestinal: abdominal distress characterised by nausea, vomiting, anorexia and
followed by fever
•
pulmonary (inhalation): brief prodrome resembling acute viral respiratory illness,
followed by rapid onset of hypoxia, dyspnea and high temperature, with X-ray evidence
of mediastinal widening
•
meningeal: acute onset of high fever possibly with convulsions and loss of consciousness,
meningeal signs and symptoms
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Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
Laboratory criteria for diagnosis
Laboratory confirmation by one or more of the following:
•
Demonstration of B. anthracis in a clinical specimen by microscopic examination of
stained smears of vesicular fluid, blood, cerebrospinal fluid, pleural fluid, stools, etc
•
Isolation of B. anthracis from a clinical specimen (e.g. blood, lesions, discharges)
•
Positive serology (ELISA, Western blot, toxin detection, chromatographic assay,
fluorescent antibody test (FAT))
Note: It may not be possible to demonstrate B. anthracis in clinical specimens if the patient
has been treated with antimicrobial agents.
Case classification
Suspected:
A case that is compatible with the clinical description and has an
epidemiological link to confirmed or suspected animal cases or
contaminated animal products
Probable:
A suspected case that has a positive reaction to allergic skin test (in nonvaccinated individuals)
Confirmed:
A suspected case that is laboratory-confirmed
9.1.3 Reporting and information flow
The local level (health care centres, private clinics and physicians, and other health personnel) is
the first point of official contact with the infected patient and the point at which surveillance
data should first be collected. Suspected rather than confirmed cases may be reported from this
level to higher levels. The tasks at this level are diagnosis and case management, including
treatment and health education plus, resources permitting, case and outbreak investigation.
The intermediate level collates and analyses data from local levels. The tasks of the intermediate
level are: case management which cannot be done at the local level; analysis of data from local
levels; epidemiological investigations, tracing sources of infection from infected animals or
animal products; monitoring of prevention activities; provision of laboratory support; feedback
of information to the local level; and reporting to the central level.
The central level formulates national policies and allocates resources. It provides technical
support (e.g. laboratory or epidemiological) to the intermediate and local levels as appropriate,
and reports to WHO.
Mandatory notification should be required for all cases of anthrax, human and animal. The
system must include zero reporting of human cases; this will avoid confusion over whether “no
report” is equivalent to “no cases”. All cases or outbreaks should be investigated. If this is not
possible, a representative sample of cases should be followed up carefully. Routine surveillance
should be carried out, particularly among high-risk groups such as those who are
45
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
occupationally exposed (e.g., selected health care providers in areas with hide processing
industry).
Routine exchange of information on anthrax cases between public health and
veterinary services should be in place.
Minimum data elements for case–based reporting are:
•
case classification (e.g. suspected, probable or confirmed)
•
clinical form of the case (cutaneous, gastrointestinal, pulmonary (inhalation), meningeal)
•
unique identification code
•
other pertinent data, such as age, sex, geographical information, occupation, date of
presentation, exposure history as well as race/nationality, date of clinical onset, treatment
and outcome, if possible.
9.2 Veterinary surveillance of anthrax in animals
9.2.1 Specific objectives
Some of the specific objectives of a veterinary surveillance programme can be summarised as
follows:
(a) Evaluate the health state of the at–risk animal populations:
•
investigate common source outbreaks and any connections between infected
herds/flocks and human cases
•
estimate the extent and geographical distribution of the disease in the animal population
•
identify high risk areas and animal populations
•
evaluate the need for interventions, establishing priorities and allocating resources
•
facilitate planning and communication in both human and animal health sectors
•
develop a database for regular communications to all persons and institutions directly
involved in anthrax control and prevention (including the media).
(b) Evaluate prevention and control activities by monitoring disease trends and
measuring
the
impact
of
programmes
(programme
evaluation
and
cost–
effectiveness).
(c) Monitor changes in the epidemiological patterns of the disease to be able to modify
control activities appropriately, by monitoring:
•
changes in the animal populations and geographical areas involved
•
incidence of anthrax in livestock in order to predict the possible occurrence in humans.
(d) Ensure regular feedback of information to all groups involved.
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Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
9.2.2 Suggested case definition
The unit of reference is usually the infected herd or flock rather than the individual animal. An
identification system for single animals or herd/flock identification should be in place for
effective surveillance.
Clinical description (see also section 3.4 and 3.5)
In non–immunized cattle, sheep or goat anthrax is usually an peracute disease characterised by
septicaemia and sudden death with bleeding from orifices and subcutaneous haemorrhages.
Other reported symptoms in cattle, horses, sheep and some wild herbivores consist of fever,
dyspnoea, agitation, convulsions followed by death. In pigs, carnivores and primates the main
symptoms are local oedema and swelling of the face and neck. Failure of the blood to clot,
absence of rigor mortis and the presence of splenomegaly are the most important necropsy
findings.
Laboratory criteria for diagnosis
Internationally recognized standard diagnostic techniques and their interpretation for diagnosis
of anthrax in animals are reported in section 3.5 and Appendix I as well as in the Manual of
Standards for Diagnostic Tests and Vaccine of the Office International des Épizooties (OIE, 1996).
Case classification
Suspected: A case that is compatible with the clinical description. In enzootic areas all sudden death
should be regarded as suspected anthrax cases.
Confirmed: A suspected case that is laboratory–confirmed. A diagnosis based on clinical signs
may be difficult, expecially when the disease occurs in a new area. Therefore a confirmatory
laboratory examination should be done as described in section 3.5 and Appendix I.
9.2.3 Reporting and information flow
The local level (field veterinarians, veterinary assistants, etc.) is the first point of official contact
with the infected herd or flock and the level at which the surveillance data should first be
collected. The tasks at this level are herd or flock diseases management (e.g. implementation of
hygienic measures, education, carcass disposal and site decontamination, etc.) and, if resources
permit, case and outbreak investigation.
In those countries where a well established and effective surveillance system is not in place, it
will be necessary to provide appropriate education at the owner farmer/village level in
recognising the disease, and instruction on whom a report should be made to.
The tasks at the intermediate level can be summarised as follows:
management
(e.g.
carcass
disposal
and
site
decontamination)
herd or flock disease
and
epidemiological
investigations which can not be done at the local level; analysis of data form local levels;
47
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
monitoring of prevention and control activities; provision of supportive laboratory tests; and
feedback of information to the local level and reporting to the central level.
At the intermediate level, consideration should be given for the establishment of an "Anthrax
Watch Team" consisting of (i) an Animal Health or Livestock Officer (ideally a veterinarian),
properly versed in methods of diagnosis, specimen collection and subsequent control measures
for anthrax, (ii) a laboratory technician trained in confirmation of the diagnosis, and (iii)
personnel trained in carcass disposal and site decontamination. The Team officers should report
to the central level (e.g. national Animal Health Center).
The central level analyses data from the intermediate level for epidemiological links, trends and
achievement of control targets, formulate national policies and allocate resources. It provides
technical support (e.g. laboratory or epidemiological) to the intermediate and local levels as
appropriate, coordination of national prevention, surveillance and control activities, feedback of
analysis data to the intermediate level, and possibly to the local level and reports to OIE.
It is implicit that appropriate national funding will be necessarily such that reporting by the
owner/farmer should incur no penalty and that reporting does not involve uncompensated cost
to the farmer/owner, the animal health officers or the laboratory as long as the appropriate and
regulated procedures are followed. Anything that discourages reporting should be avoided and
everything that encourages reporting should be embraced. Suggested approaches to ensuring
this are:
•
the reasons for discouraging or prohibiting owners from using sudden death carcasses
for food and from using or selling the hides, bones, meat, etc. from such carcasses, unless
it is established beyond doubt by the relevant veterinary officials that death was not due
to anthrax or some other transmissible disease, should be carefully explained to owners
by appropriate education programmes. It must be clear to them that butchering of
anthrax carcasses presents a highly significant risk to those involved as well as seriously
adding to ground contamination;
•
compensation to the owner should be available for any carcass proven (i) to be a case of
anthrax and (ii) to have been incinerated or disposed of by another officially approved
method;
•
quarantine should be kept as non–onerous as possible; it need not be longer than 21 days
after vaccination of the affected herd has been carried out (or 21 days after the last case if
that occurs after the vaccination campaign);
•
animal health officers should be properly equipped with specimen collection materials,
equipment and materials necessary for disinfection, clean–up and disposal and with
antibiotics and vaccine plus syringes and needles. They should also have the necessary
transport and suitable office back–up for reporting cases;
48
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
•
the laboratory technician should be supplied with the appropriate equipment and
materials for confirmation of diagnosis;
•
appropriate educational literature for all persons involved from the farmer/owner to
ministry levels should be produced. Every effort should be made to get local
understanding and popular support for the policy of carcass destruction and herd
vaccination;
•
the reporting system should be based more on incentives than penalties although
penalties for failure to report may be desirable. The reporting should not incur cost (e.g.
forms, postage, etc.) to those required to make reports;
•
treatment and vaccination of the remainder of the herd/flock and the services of the
animal health officers in assisting with cleaning and disinfection should be free of charge.
9.4 Recommended data analyses, presentation, reports
Data are used to generate indicators which consist of synthetic information from which can be
derived any particular aspect of the state of the disease (e.g. human disease incidence,
herd/flock incidence, animal disease incidence, percentage of herds/flocks vaccinated, etc.) and
its dynamics (e.g. percent variation of herd incidence in different years, percent of variation of
vaccinated animals between consecutive years, etc.), together with information of the
corresponding control programme in a population. Surveillance indicators from the veterinary
and public health services are needed to monitor the performances of the prevention,
surveillance and control activities. Data and indicators can be displayed for easy interpretation
in graphs (e.g. number of suspected/probable/confirmed cases by age, sex, month and place),
tables (e.g. number of suspected/probable/confirmed cases by age, sex, month and place) and
maps (e.g. number of suspected/probable/confirmed cases by place). The use of mapping or
other geographical information tools for surveillance of suspected endemic/epidemic and free
areas is recommended.
9.5 Strategies of anthrax surveillance in animals
In countries or areas free of anthrax, the disease is treated as an exotic or foreign disease and
measures to be adopted are based on primary prevention, mainly the control of imported
animals and animal products (see appendix IV).
In enzootic countries or areas, whether or not animal vaccination is carried out, all suspected
sudden deaths in animals should be investigated as possible cases of anthrax. Flocks or herds in
direct or indirect contact with positive human cases should be monitored. The primary
prevention measures mentioned above should also be in place. In enzootic countries or areas
where animal vaccination has been discontinued particular emphasis must then be placed on
continued surveillance.
49
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
In enzootic countries or areas without animal surveillance and control programmes the main
strategy to protect the population should be health education, promoting primary prevention in
humans (e.g. education to improve food and occupational hygiene), and specifically targeting
high risk populations.
50
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
Appendix I B Methods
A.I.1
General standard laboratory procedures for isolation,
identification, diagnosis and confirmation of anthrax
Various procedures have been followed and described in texts over the years. Those found most
satisfactory in the Anthrax Reference and Research unit, Centre for Applied Microbiology and
Research, Porton Down, Salisbury, England, is shown schematically in A.I.1.4.1 and A.I.4.1.2
below.
Type of specimen
The approach taken will depend on the type of specimen being examined which, for the
purposes of examination will fall broadly into (a) fresh specimens from untreated animals or
humans, (b) specimens from treated animals or humans, and (c) specimens from old and
decomposed animal carcasses or from animal products or environmental specimens.
A.I.1.1
Fresh specimens from untreated animals or humans
As said in section 3.5, few difficulties should be encountered in (i) identifying B. anthracis in
M'Fadyean capsule-stained smears of from blood, lymph or oedematous fluid from untreated
animals shortly before or after death from anthrax, or (ii) isolating B. anthracis from these types
of specimen. Similarly, the bacteria should be readily visible in, or isolated from, vesicular fluid
before treatment in humans, or, so long as no treatment was given, from body fluids near to
death or at post-mortem.
A.I.1.2
Specimens from treated animals and humans
Treatment of an animal suffering from anthrax may sterilize the blood and tissues even though
the animal may go on to die from the effect of the toxin. Similarly, cutaneous lesions in humans
will be quickly sterilized by treatment but will continue to pass through their stages of
evolution and resolution.
Residual forms of the capsulated bacilli may be visible in fluid smears from such animals or
persons. Isolation generally will not be possible. Confirmation of diagnosis may be possible
with a sensitive detection device for the toxin, such as that of Burans et al., (1996). It is hoped
this will come more widely available in the future.
A.I.1.3
Specimens from old or decomposed animal specimens or from
animal products or environmental specimens
As said in section 6.1, the problem likely to be encountered with this group of specimens is that
detection will frequently involve a search for relatively few B. anthracis amongst many other
51
Appendix I – Methods
Bacillus species, particularly B. cereus. The selective approach shown in the flow diagrams is
necessary.
A.I.1.4
Suggested procedure for isolation and identification of
B. anthracis and confirmation of diagnosis
See schematic flow diagrams A.I.1.4.1 and A.I.1.4.2
A.I.1.5
Molecular diagnosis
Newer technologies for diagnosis are being reported with increasing frequency for a number of
diseases. The immunochromatographic Protective Antigen assay of Burans et al., (1996) (see
A.I.3.2 below) has already been alluded to. As well as being highly reliable and very sensitive in
detection of the toxin in specimens from animals that have died of anthrax, it has the
advantages of not requiring an expensive item of equipment such as the microscope, of having
a built in control, of not requiring microbiological or veterinary/medical skills to use it and of
being simple and portable.
The polymerase chain reaction (PCR) has not yet become a standard method for direct
diagnosis of anthrax, although, as covered below (A.I.6), it has become an important test for
confirming the virulence of B. anthracis isolates.
A.I.2
Capsule visualisation
A.I.2.1
Polychrome methylene blue stain (M'Fadyean reaction)
Dating from 1903 (M'Fadyean, 1903), this probably remains both the simplest and most reliable
method of confirming the presence of capsulated B. anthracis. [NOTE: the Gram stain is not
suitable for looking for capsulated B. anthracis].
52
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
A.1.1.4.1 Flow diagram of suggested procedure for isolation and
identification of B.anthracis and confirmation of diagnosis
53
Appendix I – Methods
A.1.1.4.2 Simplified version of A.1.1.4.1 (following Route B
for old animal specimens or environmental samples
54
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
A.I.2.1.1
Staining theory
Polychrome methylene blue is a complex mixture of methylene blue and substantial amounts of
other homologs, primarily azure A and azure B, which are produced by oxidation ("ripening")
which takes place in methylene blue solution upon standing. Natural ripening takes a year or
more to complete but can be hastened by addition of 1% K2CO3 to Loeffler's alkaline methylene
blue.
Two alternative formulae (others probably exist) for Loeffler's alkaline methylene blue are given
in the table below.
Agent
Formula A
Formula B
Methylene blue
0.3 g
1.5 g
95% ethanol
30 ml
100 ml
Dissolve the methylene blue in the ethanol
KOH
100 ml of a 0.01% solution
3.3 ml of a 1% solution
Distilled/deionised water
-
330 ml
After addition of K2CO3 to 1% final concentration, distribute the stain in bottles to half-full.
Shake at intervals to aerate the contents. Test periodically for capsule staining ability. Quality
control is not complete, however, until the stain has been validated on specimens from anthrax
cases in the field (see cautions in A.I.2.1.2 below).
Polychrome methylene blue is an ingredient of Wright's and Leishmann's stains. Both these are
methanol solutions of a water-insoluble precipitate formed when eosin is added to a methylene
blue solution. In Wright's stain, the methylene blue solution contains NaHCO3 and is steamed
before the eosin is added; in Leishmann's stain, the methylene blue solution is held for 12 hours
at 65 oC followed by standing for 10 days. Giemsa stain is a deliberately formulated cocktail of
the eosinates of methylene blue with pre-purified azure A and azure B.
Romanowsky in 1891 was the first to combine eosin with methylene blue so Wright's,
Leishmann's and Giemsa stains are referred to as Romanowski stains. In theory, these stains, in
having the ingredients of polychrome methylene blue, should be usable for M'Fadyean reaction
staining; in practice, reports suggest that Giemsa stains give variable results, possibly reflecting
the variable presence of certain active but undefined impurities present in true polychrome
methylene blue. The experience of the Anthrax Reference and Research unit at Porton Down,
UK, is that the capsule will probably not be rendered visible by Giemsa stain.
We propose that the best stain to use for normal diagnostic purposes in sudden death cases is
true polychrome methylene blue - that is, the non-eosinated ripened Loeffler's methylene blue.
55
Appendix I – Methods
However, in the extensive experience of Sterne (1959), confirmed over the past few years by
Dr Pauline M. Lindeque in the Etosha National Park, Namibia, the capsule loses its affinity for
methylene blue during putrefaction and may no longer be visible with M'Fadyean's stain.
Dr Lindeque (personal communication) finds that the Giemsa-type stains show up the
characteristic square-ended shape of the anthrax bacillus better than M'Fadyean's stain and this
becomes advantageous in partially decomposed carcasses as encountered frequently in the
wildlife situation.
In the experience of Lindeque and Turnbull, a particularly reliable stain in the recent past has
been CAM's Quick-stain (C.A. Milsch [Pty] Ltd, P.O. Box 943, Krugersdorp, 1740, Republic of
South Africa).
A.I.2.1.2
Polychrome methylene blue staining procedure
(a) make a thin smear of blood, tissue fluid, etc. by spreading a small (1-5 µl) drop on a
microscope slide with the edge of a coverslip (remember this is potentially infective
material; discard the coverslip into hypochlorite solution). Air dry and fix by dipping in
absolute, or 95% methanol or ethanol for 30-60 seconds and re-drying
(b) put a large drop (approx. 20 µl) of polychrome methylene blue on the smear,
spreading with an inoculating loop to cover all parts of the smear. Leave for 30-60
seconds ("flooding the slide" with the stain is unnecessary and wasteful)
(c) wash the stain off with water into hypochlorite solution. Blot, dry and examine. The
bacteria can be seen as fine threads of varying length under the low power (10x)
objective. Under oil immersion (100x objective), the capsule is seen clearly (pink)
surrounding the blue-black, often square-ended bacilli. (Discard the blotting paper and
slide into containers destined for autoclaving or into hypochlorite solution when finished
with).
Cautions on negatives
Very little is known about the development and changing nature of the capsule with time, but it
has been noted by Turnbull and Lindeque (unpublished), and in occasional other personal
communications, that commercial polychrome methylene blue may fail to reveal the capsule in
specimens from anthrax victims in the field while being able to do so with artificially induced
capsules obtained by in vitro growth of the organisms in blood or on bicarbonate agar (see
A.I.2.2 below). It is suspected that this is related to inadequate maturation of the stain. The
consequences are considerable, however, and laboratories are urged to ensure new stocks are
thoroughly tested for reliability before old stocks are finished and discarded.
A.I.2.1.3
India ink method
This, of course, is not a true staining method but highlights the capsule as a transparent halo
around the bacillus. With good capsule preparations, such as blood from a freshly-dead animal
56
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
or smears of bacilli from mucoid colonies on bicarbonate agar grown under CO2 (see A.I.2.2.2
below), it is satisfactory. It may be less sensitive when smaller numbers of anthrax bacilli are
present or when the bacilli are dead and disintegrating as may be the case in specimens from
old carcasses or from animals/humans that were treated before the specimens were collected.
Procedure
Premix a loopful of the blood or other tissue fluid with a small drop of India ink on a clean slide
such that a thin layer results when a cover slip is placed on top and pressed down lightly. If the
India ink is too dark, dilute appropriately with water.
As before, the bacteria can be found by scanning under low power (10x objective) and then
examined under oil immersion (100x) for the presence of the capsule.
A.I.2.2
Induction of capsule formation
A.I.2.2.1
In blood
As indicated in the flow diagrams (A.I.1.4 above), capsule formation can be demonstrated by
transferring a pin-head quantity of growth from a suspect colony to approximately 2.5 ml
defibrinated blood (see next paragraph) in a sterile test tube or small bottle and incubating
5 hours to overnight. A smear is made from the blood and stained and examined as described
above.
Theoretically blood from any species should do but, in our experience, there is great animal-toanimal variation and it is necessary to identify a source of reliable blood giving good capsule
production. Defibrinated horse blood seems to be best. In the absence of a local source, this may
be obtained commercially from Tissue Culture Services (TCS Biologicals Ltd, Botolph Claydon,
Bucks MK18, 2LR, UK, phone 44 296 714071, fax 44 296 714806).
A.I.2.2.2
On agar plates
Plate the suspect colony onto nutrient agar containing 0.7% sodium bicarbonate (see Appendix
II) and incubate overnight at 37 oC under CO2 (a candle jar does very well for general purposes,
but 20% CO2, as supplied from a gas cylinder is best if it is necessary to be specific). Capsuleforming strains of B. anthracis form mucoid colonies (non-capsulating strains are rough). Smears
of these can be stained and examined as described above.
A.I.3
Antigen detection tests
A.I.3.1
Ascoli precipitin test (thermostable antigen test)
This test dating from 1911 (Ascoli, 1911) was designed to detect B. anthracis antigens in the
tissues of animals being utilized in animal by-products and thereby to reveal when these
products contained ingredients originating from animals that had died of anthrax; i.e., its
purpose is to supply rapid retrospective evidence of anthrax infection in an animal. Over the
57
Appendix I – Methods
years, it has been one of the most valuable tools for controlling anthrax in most European
countries, and it remains in use, particularly in eastern Europe.
It needs to be borne in mind that this test is not rigorously specific for B. anthracis. The
thermostable antigens involved are common to other Bacillus species so the test depends on the
fact that the only Bacillus likely to have proliferated within and throughout an animal
depositing extensive precipitating antigens in the tissues is B. anthracis.
The test is not suitable for detection of B. anthracis in environmental specimens; numerous other
Bacillus species can be expected to occur in these. Application of the immunochromatographic
assay of Burans et al., (1996) (A.I.3.2 below) may be the replacement of the future.
Procedure
(a) chop or slice the specimen into fine pieces or strips
(b) boil approximately 2 g of the specimen for 5 min in 5 ml saline containing 1:100
(final concentration) acetic acid. Alternatively, soak in saline containing 0.5% phenol
for 24-48 hours in a refrigerator
(c) after cooling, filter through filter paper till completely clear
(d) insert a few drops of the antiserum in the bottom of a small test-tube and carefully
add some of the filtrate from (b) down the side of the tube to form a layer of antigen
above the antiserum. (As an alternative to using a test-tube, and more economical on
the antisera, capillary tubes can be used as in the Lancefield test for streptococcal
grouping)
(e) appropriate positive and negative specimen controls should be included.
Antiserum for the Ascoli test
(Commercially prepared donkey or mule serum is available from Bioveta plc, Komenského 212, 683 23
Ivanovice na Hané, Czech Republic, fax +42 507 932 84)
To prepare in rabbits, on days 1 and 14, the rabbits should be inoculated subcutaneously with
the animal anthrax vaccine (Sterne strain 34F2). On days 28 and 35, further subcutaneous
injections of 0.05 ml of a suspension in physiological saline of a mixture of several strains of
virulent B. anthracis should be administered. The viable count of this suspension should not
exceed 100 000 colony-forming units/ml. After a further 10 days, a test-bleed will reveal the
activity of the antiserum; if not adequate, further injections of the suspension of virulent
B. anthracis should be administered at 7-10 day intervals.
If considerations of safety prevent the use of live virulent B. anthracis, the mixture of several
strains of B. anthracis can be suspended to a final count of 108-109/ml in physiological saline
containing 0.2% formalin. This is held until sterile (at least 2 weeks). After the vaccine strain
58
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
inoculations on days 1 and 14 as before, increasing doses of 0.1, 0.5, 1 and 2 ml of the formalized
suspension should be administered intravenously at approximately 4-5 day intervals. A test
bleed should be done 10 days after the last injection. Further 2 ml doses can be administered if
the titre is not adequate initially.
A.I.3.2
Other antigen detection tests
Over the years numerous attempts have been made to identify truly anthrax-specific antigens
(i.e. antigens not shared by other Bacillus species) and to design antigen-based detection tests for
B. anthracis. Most of the resulting systems did not reach the point of being tried out extensively
in the field or were only available to highly specialized laboratories.
Although there is evidence that a variety of anthrax-specific antigens do exist, the only ones that
are at all readily isolated and purified are the toxin antigens. Capsular antigen is probably also
fairly specific but is poorly immunogenic and, therefore, of limited use outside the specialized
laboratory.
The highly specific immunochromatographic assay of Burans et al., (1996) utilizes a monoclonal
capture antibody to the anthrax protective antigen (PA) bound to a nitrocellulose membrane,
and a second monoclonal antibody specific for a different epitope of PA bound to colloidal gold
particles which become visible when they accumulate at the capture sites. The assay can detect
as little as 25 ng/ml of PA and is performed in a few minutes without the need for special
reagents. It therefore lends itself to direct diagnosis of cases of anthrax by detection of PA in the
blood or body fluids, or to retrospective analysis of extracts from the types of sample of animal
origin for which the Ascoli test was designed.
A.I.4
Isolation in animals
On account of increasing concern to eliminate the use of laboratory animals wherever possible,
and of the increasing reliability and sophistication of alternative in vitro methods, the use of
animals for isolation or confirmation of identity of B. anthracis can and should generally be
avoided. It should be noted that EC Directive 86/609/EEC relating to protection of animals
used for experimental and other scientific purposes pertains to members of the EU.
There still are occasions, however, such as those where potential legal disputes may be
involved, when confirmation of the presence or the virulence of B. anthracis is necessary. In the
absence of a selective enrichment system (see 6.1), inoculation of mice or guinea pigs, essentially
as done more than a century ago by Pasteur, is still probably the most sensitive isolation
method. Pending the development of equally sensitive conventional immunological or DNAbased techniques, animal tests may offer the only chance of (i) confirmation of diagnosis in
certain situations such as in the case of individuals or animals that were treated before
specimens were taken, or (ii) detection of the organism when present in very low numbers in
environmental samples, or in environmental samples containing sporostatic chemicals.
59
Appendix I – Methods
Confirmation of identity or of virulence can be done by injecting light suspensions
(approximately 10 000 colony-forming units/ml) into mice (0.05-0.1 ml subcutaneously) or
guinea pigs (0.1-0.2 ml intramuscularly). Virulent B. anthracis will kill the animals at about 42-48
hours; M'Fadyean-stained blood smears examined at death will reveal large numbers of the
capsulated bacilli which can also be isolated and confirmed bacteriologically.
In the rare situation in which it is necessary to use animals to isolate B. anthracis from soil or
other environmental samples, the animals should be inoculated the day before with
subcutaneous doses of mixed gas-gangrene antisera (extremely difficult to obtain, however) and
anti-tetanus serum. Heated (62.5 oC for 15 min) soil extracts, as prepared for plating on selective
or non-selective agar (see A.I.1.4.1), are then injected (0.05-0.1 ml subcutaneously in a mouse or
up to 0.4 ml intramuscularly in a guinea pig [0.2 ml in each thigh muscle]). M'Fadyean-stained
blood smears from any animals that die are examined for the presence of the typical capsulated
B. anthracis which can also be isolated and confirmed bacteriologically.
A.I.5
Serology
Effective serological enzyme immunoassays (EIA) for confirmation of the diagnosis of anthrax
have been designed now and have proved to be useful diagnostic, epidemiological and research
aids (Turnbull et al., 1992). The usual provisos for any serological confirmatory test apply,
namely, that (i) two or more serum samples taken 2-4 weeks apart will give greater diagnostic
reliability, (ii) if only one serum sample is collected, it will be of greater diagnostic value if
collected more than a week after onset of symptoms, and (iii) negative or weak results be
interpreted in the light of treatment the patient or animal may have received early on in the
course of the infection. The last is particularly important in anthrax since, as covered under
section 7 on treatment, antibiotic therapy rapidly kills infecting B. anthracis and, if carried out
early enough in an infected individual, may prevent the elaboration of sufficient antigen to
induce a detectable immune response.
Available immunoassays for anthrax are mostly based on antibodies to the toxin antigens,
primarily the protective antigen component of the toxin (see Section 5 and A.I.3.2). Although
not difficult to perform (any standard EIA methodology will do), they are, at present, confined
to a few specialist laboratories capable of preparing the necessary purified toxin antigens.
It is hoped that an immunochromatographic assay for detecting anti-PA antibody, analagous to
the assay for detecting PA (A.I.3.2), may become available in the foreseeable future for
retrospective confirmation of diagnosis.
A.I.6
PCR
Template DNA for PCR from B. anthracis colonies can be prepared by transferring a loopful of
growth from a young culture on nutrient agar to 25 µl of sterile deionised (or distilled) water
60
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
(SDW) and heating to 95 oC for 10 minutes. Following cooling to approximately 4 oC, and brief
centrifugation, 5 µl of this is taken for the PCR reaction.
Suitable primers (Hutson et al., 1993; Beyer et al., 1996) for confirming the presence of the pX01
and pX02 plasmids are given in the following table:
Target
Primer ID
Sequence 5'-3'
Product size
Conc.
PA
PA 5
3048-3029
TCC TAA CAC TAA
CGA AGT CG
596 bp
1 mM
PA 8
2452-2471
GAG GTA GAA GGA
TAT ACG GT
1234
1411-1430
CTG AGC CAT TAA
TCG ATA TG
846 bp
0.2 mM
1301
2257-2238
TCC CAC TTA CGT
AAT CTG AG
Capsule
PCR can be carried out in 50 µl volumes using the above primers, 200 µM each of dATP, dCTP,
dTTP and dGTP, 1.5 mM MgCl2 and 2.5 units of amplitaq polymerase all in NH4 buffer,
followed by addition of 5 µl of the template DNA.
Alternatively, "Ready-To-GoT" beads are available from Pharmacia Biotech (Uppsala, Sweden,
product number 27-9555-01). These are pre-mixed, pre-dispensed, dried beads, stable at room
temperature, containing all the necessary reagents, except primer and template, for performing
25 µl PCR reactions. The template can be added in a 2.5 µl volume.
For strains of B. anthracis lacking both pX01 and pX02, the primers specific to the S-layer shown
below (J.E. Bowen and C.P. Quinn, unpublished; kindly supplied by J.E. Bowen) can be
included to confirm the presence of B. anthracis chromosomal DNA. It is probably advisable to
run the S-layer primers alone rather than in multiplexed with PA and capsule primers.
Target
Primer ID
Sequence 5'-3'
Product size
Conc.
S–layer
Upper
CGC GTT TCT
ATG GCA TCT
CTT CT
639 bp
0.2 mM
391–413
lower
1029–1008
TTC TGA AGC
TGG CGT TAC
AAA T
The following PCR cycle can be used: 1 x 95 oC for 5 min; 30 x (95 oC for 0.5 min followed by
55 oC for 0.5 min followed by 72 oC for 0.5 min); 1 x 72 oC 5 min; cool to 4 oC.
61
Appendix I – Methods
After PCR 10% of the reaction volume of tracking dye (0.02% xylene cyanol, 0.02%
bromophenol blue and 50% glycerol) is added to each PCR tube, and 10 µl loaded into wells on
a 1% agarose gel in TBE (45 mM Tris-base, 45 mM boric acid, 1 mM EDTA pH 8.0, diluted 1 in
10) and the gel electrophoresed for 1 h at 80 V followed by staining in ethidium bromide
solution for visualisation under UV light. A 1-kilobase ladder for size markers should be
included in the outer wells of the gel.
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Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
Appendix II - Media and Reagents
A.II.1
Polymyxin blood agar
This is useful for testing unheated suspensions of old decomposed or processed animal
specimens or environmental specimens and reduces or prevents growth of many Gram
negative species.
Polymyxin B sulphate should be added to a level of 100 000 units per litre of medium to the
cooled blood agar base at the same time as adding the blood.
A.II.1.1
Polymyxin-lysozyme-EDTA-thallous acetate (PLET) agar
PLET (Knisely, 1966) is the best selective agar currently available for isolation of B. anthracis
from animal or environmental specimens contaminated with other organisms including other
Bacillus species.
Difco heart infusion agar (or Difco heart infusion broth with other agar base) (Difco
Laboratories, Detroit, MI 48232-7058, USA) is made up according to the manufacturer's
instructions. EDTA (0.3 g/l) and thallous acetate (0.04 g/l) are added before autoclaving. (Note:
thallous acetate is poisonous and should be handled with care; avoid skin contact or inhalation of the
powder while weighing out). Heart infusion agars of other manufacturers or other nutrient bases,
such as brain-heart infusion, can be made to work, but the optimal concentrations need to be
determined; the concentrations recommended for normal use are unlikely to be optimal for use
in PLET. A starting point for determination of optimal concentration is 25 g/l of dehydrated
broth plus agar at the manufacturer's recommended concentration.
After autoclaving, the agar is cooled to 50 oC and polymyxin (30 000 units/l) and lysozyme (300
000 units/l) are added. (It is important that the agar is left at 50 oC for long enough to ensure
that this temperature has been reached throughout the medium before the polymyxin and
lysozyme are added). After swirling to ensure even suspension of the ingredients, the agar is
poured into petri dishes.
Sporulation agar
Peptone USP
Yeast extract
NaCl
Dextrose
Agar
MnSO4
Water
15.0 g
3.0 g
6.0 g
1.6 g
12.0 g
0.1 g
1000 ml
Sterilize at 121 oC for 15 minutes, cool to 55 oC, and dispense into the appropriate containers
(bottles, petri dishes, etc.) to set.
63
Appendix II – Media and Reagents
0.7% bicarbonate agar
The agar is prepared by reconstituting enough nutrient agar base powder for 100 ml of agar in
90 ml of water. Autoclave and cool to 50 °C in a water bath. Add 10 ml of a filter-sterilized
(0.22-0.45 µm filter) 7 % solution of sodium bicarbonate. Mix and pour into Petri dishes.
The source of the nutrient agar may be important. If capsule formation is not obtained (see
A.I.2.2.2), agar from another source should be tried. Oxoid nutrient agar (Unipath Ltd, Wade
Road, Basingstoke, Hampshire RG24 8PW, UK, Fax +44 1256 463388) appears to be reliable.
A.II.1.2
Diagnostic gamma-phage
As reviewed elsewhere (Redmond et al., 1996), anthrax-specific phages were first isolated in the
1950s. The specifically-named gamma phage was first reported in 1955 and became the
standard anthrax diagnostic phage, although it is clear that it is just one of a family of closely
related anthrax phages (Redmond et al., 1996). On the rare occasion phage-negative B. anthracis
or phage-positive B. cereus are encountered. The phage must, therefore be used in conjunction
with the other tests indicated in 6.2 and A.I.1.4. With that proviso, it is a very useful and reliable
test.
Phage suspensions may be obtained from central veterinary laboratories or central public health
laboratories.
The phage can be propagated and concentrated by the following protocol:
Stage one
i)
Spread a blood agar (BA) plate of the Sterne vaccine strain of B. anthracis. Incubate
at 37 oC overnight (o/n)
ii)
Inoculate approximately 10 ml of nutrient broth (NB) with growth from the BA
plate and incubate at 37 oC for about 4 hours (until just cloudy), then refrigerate.
iii)
Spread 100 µl of the culture from (ii) on three pre-dried BA plates and incubate at
37 oC for 30-60 min.
iv)
Spread 100 µl of the phage suspension to be amplified over the same plates.
Incubate at 37 oC o/n.
v)
Harvest the phage-lysed growth on the BA plate in 5 ml of NB followed by a
second Awash@ of 5 ml NB. Incubate at 37 oC o/n.
vi)
Filter (0.45 µm) and count by dropping 20 µl drops (3 drops per dilution) of 10-fold
dilutions of the filtrate in saline onto lawns of the B. anthracis culture prepared as
in (iii).
64
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
Stage two
This is essentially the same procedure as Stage one, only using the filtrate from (vi) to harvest
the phage from the plates, i.e.:
vii)
Prepare 3 Sterne strain lawns on BA, as in (iii). Incubate at 37 oC for 30-60 min.
viii)
Spread 100 µl phage from (vi). Incubate at 37 oC o/n.
ix)
To 9 ml of filtrate from (vi), add 1 ml of 10x concentrated NB.
x)
Harvest the phage from (viii) with 5 ml of (ix), followed by a second 5 ml wash
with the rest of (ix).
xi)
Add 10 ml of 1x NB.
xii)
Incubate at 37 oC o/n, filter and count.
Stage three
xiii)
Inoculate 100 ml of brain-heart infusion broth with approximately 2.5 ml of the
culture from (ii). Incubate on a rotary shaker at 37 oC until just turbid.
xiv)
Add the 20 ml of filtrate from (xii) and continue incubation o/n.
xv)
The resultant filtrate is checked for sterility and titrated in ten-fold dilutions on
lawns of the vaccine strain as in (vi) to determine the concentration of the phage.
This should be of the order of 108 - 109 plaque forming units per ml.
65
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
Appendix III
Disinfection, Decontamination and
Incineration of Carcasses
A.III.1
Introduction
This appendix is concerned with control of anthrax through targeting the reservoirs of
B. anthracis, taking into account the chemical and physical decontamination procedures it is
susceptible to, and detailing the practical details of these procedures.
Attention is drawn to the importance of handling the concentrated liquid disinfectants referred to with
caution using gloves and aprons or overalls and goggles or eye shields to prevent contact with skin or
eyes. Clean water for immediate washing or showering should be at hand for immediate washing or
showering in the event of an accident while handling concentrated disinfectants. All containers of
disinfectants should be properly and accurately labelled as to their contents. Peroxides may be explosive
under certain circumstances.
Appropriate (chemical) respirators should be worn by personnel disinfecting or fumigating closed spaces
(rooms, stables, etc.) and when opening up such places to ventilate them at the end of the disinfection or
fumigation procedure.
Lists of approved disinfectants published periodically in some countries can be misleading
when selecting the sporicidal disinfectant to use for B. anthracis and, as is clear from Section 8,
procedures which are both practical and effective have yet to be worked out for numerous
situations. Probably because B. anthracis is an obligate pathogen and depends for the continued
existence of the species on the survival of the spores in the environment between infections of
successive hosts, it appears to produce particularly tenacious spores. The results are that
(i) only a few fairly formidable chemicals and procedures (Section 8.3.2) are capable of reliably
killing anthrax spores, and (ii) information on the sporicidal activities of disinfectants based on
other Bacillus species should be viewed with caution.
A.III.2
Disinfectants
The principal disinfecting agents for destruction of anthrax spores are formaldehyde,
glutaraldehyde (at pH 8.0-8.5), hydrogen peroxide and peracetic acid (Dietz and Böhm, 1980;
Böhm, 1990). Hypochlorites are sporicidial but are rapidly neutralized by organic matter and,
therefore, while good for items like laboratory surfaces (not wooden ones) or glassware, or for
water treatment, are unsuitable for disinfecting most environmental sites or materials.
Hydrogen peroxide and peracetic acid are not appropriate if blood is present. The agents
should have been tested for their sporicidal activity according to recommendations below and
67
Appendix III – Disinfection, Decontamination and Incineration of Carcasses
validity test results of two independent laboratories should be included on the manufacturer's
product information sheet.
As said in 8.3.3, for environmental protection and human and animal health hazard reasons,
alternatives to formaldehyde as the recommended general purpose disinfectant have been
sought. The information in this Appendix will need to be updated in the future when and if
satisfactory alternatives have been identified.
If heat treatment or incineration of the contaminated material is possible, this should be done in
preference to chemical decontamination and disinfection. For certain materials or animal byproducts, irradiation with gamma rays or particle bombardment or fumigation with a gaseous
disinfectant such as ethylene oxide may be appropriate (see also Sections 8.3.10-8.3.12).
A.III.2.1
Efficacy tests for sporicidal disinfectants
Useful information on the sporicidal efficacies of disinfectant solutions can be obtained from the
Kelsey-Sykes capacity test (Kelsey and Sykes, 1969), which is now published as a British
Standard, BS 6905:1987 (Estimation of the Concentration of Disinfectants used in 'Dirty’
Conditions in Hospitals by the Modified Kelsey-Sykes Test). However, it is officially concerned
with the bactericidal, rather than the sporicidal efficacy of a product. A US Association of
Official Analytical Chemists method (AOAC Official Method 966.04 - Sporicidal Activity of
Disinfectants) uses surgical silk sutures and porcelain "penicylinders". At present there is no
European Standard method for sporicidal efficacy testing. A procedure based on the methods
accepted and used in Germany (Anon, 1972; 1976), also aimed at testing sporicidal efficacy on
surfaces rather than in liquid suspensions, was detailed in the previous edition of these
guidelines (Turnbull, 1993).
A.III.2.2
Titration of available chlorine in hypochlorite solutions
Hypochlorite is a strong oxidising agent and will oxidize iodide ions to form elemental iodine.
The iodine so formed may be titrated with standard sodium thiosulphate using starch solution
as an indicator. The starch solution can be made by making a paste of 0.1 g of soluble starch
with a little water and transferring the paste to 100 ml of boiling water. Boil for one minute.
Allow the solution to cool and add 2 to 3 g of potassium iodide. The solution should be kept in
a stoppered bottle.
(i) The chlorine solution to be tested should be diluted to an estimated 10 000 ppm (see 8.3.4).
(ii) Fill a clean 50 ml burette with 0.1M sodium thiosulphate solution. (iii) Accurately pipette
5 ml of the solution being tested into a clean flask and acidify with 5 ml of glacial acetic acid.
Then add approximately 0.2 to 0.3 g of potassium iodide to the solution which now becomes
orange in colour. (iv) Titrate the mixture by adding the sodium thiosulphate from the burette
until the colour is pale yellow. (v) Add 5 drops of the starch solution and continue the titration
until the blue colour of the starch is just detectable (it will look slightly pink now). (vi) Note the
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Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
burette reading and then continue to add the sodium thiosulphate dropwise. The burette
reading immediately preceding the observation of a colourless solution is the end point.
Note the volume of sodium thiosulphate added from the burette and calculate the available
chlorine in the test solution from the expression:
1 ml 0.1M sodium thiosulphate / 0.00355 g chlorine
Correcting for the original dilution of the concentrated sample
and converting to a percentage,
Available chlorine (%w/v) = Titre x 0.00355 x 10 x 20.
A.III.3
Guidelines on incineration of carcasses
(Modified from MAFF, 1992)
The underlying physical principle that has to be addressed in designing an efficient incineration
procedure is that material underneath a flame can remain cool so that contaminated materials
(ground, soil, carcass remains, etc.) that remain below the flames during incineration will
remain contaminated. A number of approaches can be taken to ensure incineration is fully
effective and the one of choice depends on available resources and other circumstances. In some
countries, portable incinerators with gas-fired jets at base level and 0.25 m above base level are
available. Similarly flame guns are available in some countries; in directing the flames
downwards, these provide a good way of ensuring complete and effective incineration.
The following suggestions are offered to cover the different circumstances which may be
encountered. It should be pointed out that all the procedures described below take many hours
for a large domestic animal, such as a cow.
A.III.3.1
Pit method
For a large animal, a pit about 0.5 m deep and exceeding the length and breadth of the carcass
by about 0.25 m on each side should be dug. A trench approximately 0.25 m wide by 0.25 m
deep should be dug along the length of the centre of the pit extending beyond the ends by
about 0.75 m; this serves the purpose of allowing air for the fire under the carcass. The bottom
of the pit and the trench should be covered with straw which is then soaked in kerosene.
Above the kerosene-soaked straw, place a few pieces of heavy timber (or other type of beams
which will hold the carcass well above the bottom of the pit) across the pit and then scatter thin
pieces of wood over beams and straw. Then add larger pieces of wood and, if available, coal,
until the pit is filled top ground level. Saturate all the fuel with kerosene.
The carcass can then be drawn onto the pyre, preferably propped up so that it is lying on its
back. Further kerosene should be poured over the carcass. The fire is started at either end of the
longitudinal trench. Once the incineration is well underway (probably after about the first
69
Appendix III – Disinfection, Decontamination and Incineration of Carcasses
hour), the pyre should be covered with corrugated iron or other metal sheeting in such a way as
to reduce heat loss without cutting off the ventilation.
The approximate quantities of fuel that will be needed for a large domestic animal are 20 kg of
straw, 10 litres of kerosene, and either 2 tonnes of wood or 0.5 tonnes of wood and 0.5 tonnes of
coal. Note: it will be necessary to decontaminate the ground where the carcass lay and from
where it was removed to the pit and also the ground, equipment, etc. contaminated during this
moving process (see Section 8.3.8, 8.3.9).
A.III.3.2
Raised carcass method
This method may be appropriate when labour is scarce or the ground unsuitable for the
construction of a pit.
Place straw over a 2 m by 1.5 m area. Place two wooden beams (approximately 2 m lengths of
small tree trunks, railway sleepers, etc.) over the straw parallel to each other and about 1.25 m
apart and aligned with the direction of the prevailing wind. Soak the straw with kerosene and
cover with thin and thick pieces of wood and coal if available as in A.III.3.1. Place further stout
cross-pieces of wood or other material across the two main beams to support the carcass. The
fuel (wood or coal) is banked up either side (but not at the ends where the air must be allowed
to enter under the carcass) of the carcass and fuel and carcass further doused with kerosene.
The fire can then be started and as before, when well underway, it should be covered with
metal sheeting to retain heat but without inhibiting ventilation. Further fuel should be added if
and when necessary.
Rather more fuel may be required than with the pit method. For a large domestic animal, an
estimate is 0.75 tonnes coal + 0.5 tonnes wood or, if coal is unavailable, approximately 3 tonnes
of wood, plus 20 kg straw and 20 litres of kerosene.
As with A.III.3.1, it will be necessary to decontaminate the site where the carcass lay before
incineration and the ground and equipment contaminated in moving it from there to the pyre
(see Section 8.3.8, 8.3.9).
A.III.3.3
Commercial incinerators
(see also section 8.1.3)
A.III.3.3.1
Down-directed blow torches
An example of the use of down-directed blow-torches for incineration of a carcass is shown in
Figures K and L.
A.III.3.3.2
Portable incinerator
An example of incineration of a bovine anthrax carcass in a portable incinerator is shown in
Figures G-J.
70
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
A.III.3.3.3
Centralized incinerators
Largely since the advent of the focus on BSE, commercial incinerators capable of taking whole
bovine carcasses have now become available. It seems feasible for an anthrax carcass to be wellbagged in the same manner as if it was being taken to a rendering facility, and to be taken for
incineration at one of these types of incinerator. While this would appear to be perfectly
practicable, under the current legislation in certain countries, there would be problems
obtaining movement orders permitting the transport of the carcass.
As with A.III.3.1 and A.III.3.2, it will be necessary to decontaminate the site where the carcass
lay before removal and any equipment contaminated when bagging it.
71
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
Appendix IV
International Zoo-Sanitary Code
(OIE 1997b)
Chapter 3.1.1 – ANTHRAX
Preamble
For vaccine standards, reference should be made to the Manual (OIE, 1996).
Article 3.1.1.1
For the purposes of this Code, the incubation period for anthrax shall be 20 days.
Article 3.1.1.2
Veterinary Administrations of importing countries should require:
for domestic ruminants, equines and pigs the presentation of an international animal health
certificate attesting that the animals:
1.
showed no clinical signs of anthrax on the day of shipment;
2.
were kept for 20 days prior to shipment in an establishment in which no case of
anthrax was officially reported during that period; and/or
3.
were vaccinated, not less than 20 days and not more than six months prior to
shipment.
Article 3.1.1.3
Veterinary Administrations of importing countries should require:
for wild ruminants, equines and pigs the presentation of an international animal health certificate
attesting that the animals:
1.
showed no clinical signs of anthrax on the day of shipment;
2.
were vaccinated not less than 20 days and not more than six months prior to
shipment.
73
Appendix IV – International Zoo-Sanitary Code
Article 3.1.1.4
Veterinary Administrations of importing countries should require:
for products of animal origin (from ruminants, equines and pigs) destined for use in animal feeding,
the presentation of an international sanitary certificate attesting that these products:
1.
originate from healthy animals;
2.
have been processed to ensure the destruction of both bacillary and spore forms of
Bacillus anthracis.
Article 3.1.1.5
Veterinary Administrations of importing countries should require:
for products of animal origin (from ruminants, equine and pigs) destined for industrial use the
presentation of an international sanitary certificate attesting that these products:
74
1.
originate from healthy animals;
2.
have been processed to ensure the destruction of both bacillary and spore forms of
Bacillus anthracis;
3.
have been kept in areas where anthrax is not prevalent.
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
Appendix V - Vaccines
A.V.1
General
The history and theory of anthrax vaccines is covered in Section 8.4. This Appendix lists the
names, addresses, telephone and fax numbers and other salient data that could be traced on
available anthrax vaccines. The list is almost certainly not exhaustive and WHO would like to
hear from any manufacturer not listed. Manufacturers are requested to inform WHO of any
information that is not correct; corrections will be published in subsequent supplements or
revisions of the guidelines.
Important note:
The list is supplied for the benefit of users of the guidelines but does not
represent endorsement of the products by the World Health Organization (WHO). While every
attempt has been made to ensure the data given are correct, WHO does not guarantee the
absolute accuracy of the information supplied in these lists. For confirmation of the data and for
further information about the products, the reader should contact the relevant manufacturer
directly.
A.V.1.1
Veterinary vaccines
For the most part, the veterinary vaccines appear to have been manufactured broadly in line
with the WHO "Requirements for Anthrax Spore Vaccine" (WHO, 1967) and using spores of the
34F2 "Sterne" strain suspended in glycerol with saponin added as an adjuvant essentially as first
formulated by Sterne (1939). One vaccine is still formulated with the Pasteur strains dating from
before Sterne's vaccine while at least two vaccines use alternative vaccine strains.
For further information, enquiries should be addressed to the manufacturers directly.
Cautions applicable to all these vaccines are:
•
store in a refrigerator; do not freeze (repeated freeze-thawing will result in reduced
inocula)
•
antibiotic treatment will interfere with vaccine performance. Animals being
vaccinated should not receive antibiotics for several days before or after vaccination
(for example, if cattle are on anti-mastitis therapy, the vaccine may be rendered
ineffective)
•
animals should not be vaccinated later than 6 weeks before slaughter for human
consumption
•
Sterne himself (1937; 1939; Sterne et al., 1939) noted that horses were slow to develop
immunity following vaccination; some manufacturers recommend that the initial
schedule in the horse should be two doses with a one-month interval (and a single
annual booster thereafter)
75
Appendix V – Vaccines
•
goats are well-known as being prone to severe reactions in response to the vaccine.
One possible approach to vaccination of goats is an initial schedule of two
inoculations one month apart with the first dose being one-quarter of the standard
recommended dose ("pre-inoculation dose") and the second dose being the standard
recommended dose. A single annual booster may be administered thereafter. One
manufacturer recommends that injection of the vaccine in goats should be done in the
tail-fold region (compared with the neck region in most species)
•
injection should be made through an area of clean, dry skin
•
pregnant animals should not be vaccinated unless the risk to them of acquiring
anthrax is very high
•
being a live spore vaccine, leftover vaccine vials, used syringes, needles and other
contaminated items should be disinfected, autoclaved or incinerated after completion
of the operation (see Section 8.3.9)
•
in the event of accidental self-inoculation by the operator, gentle pressure should be
applied to the wound to squeeze out any inoculum followed by thorough washing
with soap and water. If saponin is included in the vaccine, there may be a painful
local reaction at the site of inoculation. Medical advice should be sought if infection
sets in.
A.V.2
Vaccine failures in livestock
Questions do arise from time to time regarding cases of anthrax which occur in herds which
have been vaccinated, or about continuing cases after vaccination to control outbreaks. Usually
it is not possible to identify the specific reasons for these vaccine failures, but the following
points may be helpful:
Tests in guinea pigs show that:
(a) the antibody response in different individuals can vary. Variable antibody titres are a
feature in animals receiving a particular dose of a live spore vaccine.
(b) receiving the correct dose is important. Very marked differences in titres are seen in
groups receiving one million and ten million spores in a dose.
(c) protection tends to be less than 100% in animals if (i) they have only received a single
dose, and (ii) the doses were less than 107 spores.
Extrapolating this to livestock, circumstances which lead to the animals not receiving the correct
dose are probably important. Examples of such circumstances in mass vaccination campaigns
might be:
•
76
the vaccine spores in the reservoir of the automatic syringe settle, so some animals
get a reduced dose
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
•
the reservoir containing the vaccine runs out and some animals, although injected,
actually receive no vaccine
•
the needle gets blocked, or the needles blunted, resulting in a reduced dose or no
vaccine being administered
•
some of the animals are fairly wild and move violently before delivery of the vaccine
is complete
Other considerations that may lead to vaccine failures are:
•
some or all of the animals are on antibiotics, for treatment or growth promotion
•
the animals were too young at vaccination, per se or because the vaccine effect was
neutralized by maternal antibody
•
the potency of the vaccine itself has fallen for reasons beyond the control of the
person or team carrying out the vaccination.
Enzyme immunoassay studies in the Anthrax Reference and Research Laboratory, CAMR,
Porton Down, UK, on cattle with a range of vaccination histories have revealed a great
variability in titres among animals with identical vaccination records; a few even exhibited low
or negative titres despite multiple boosters (unpublished results). The reasons for this
variability were not identified. It was not possible to establish a correlation, or lack of it,
between low titre and succumbing to anthrax. However, the observation does serve to
underscore the need to take considerable care to ensure all animals receive the correct dose in a
vaccination campaign and also that all other conditions are favourable to optimal vaccine
performance at the time of the campaign.
77
Appendix V – Vaccines
A.V.3
Manufacturers of live spore (veterinary) vaccines
MANUFACTURERS OF VETERINARY ANTHRAX VACCINES
Country
Australia
Bangladesh
Manufacturer
CSL Ltd.
45 Poplar Road
Parkville
Victoria 3052
Tel.: +61 3 9389 1372
Fax: +61 3 9389 1100
Description
Strain: 34F2
Adjuvant:
saponin
Dose*
Sheep, goats, pigs:
0.5 ml s.c.
Cattle: 1 ml s.c.
Horses: 2 s.c. doses of
1ml separated by a
1-month interval
Animal Husbandry Laboratory
Mohakhali
Dhaka
Animal Husbandry Laboratory
Cossilla
Biological Products Unit
Central Veterinary Laboratory
New Haw
Surrey KT15 3NB
Tel.: +44 1932 357641
Fax: +44 1932 357701
Strain: 34F2
China
(People's
Republic)
National Control Institute of
Veterinary Bioproducts &
Pharmaceuticals
Ministry of Agriculture
30 Baishiqiao Road
Beijing 100081
Tel.: +86 2568844 ext.261
Fax: +86 831 6545
Strain: 34F2
Colombia
S.A.
Laboratorios Erma
Avenida El Dorado N 90-31
A.A. 98835
Bogota D.E.
Tel.: +57 1 295 0900
Fax: +57 1 410 2424
Strain: 34F2
Laboratorios Probiol Ltda
Diagonal 183 N 41-71
Apartado aereo 8001
Bogota
Tel.: +57 1 671 1023
Fax: +57 1 671 1066
Strain 34F2
Laboratorios ERMA
Av. El Dorado No. 90-31
Apartado Aereo 98835
Tel:/Fax: (+57-1) 2950900/4102410
Santafé de Bogotá.
E-mail: Laberma@
col.1.telecom.com.co
Sterne/Saponin
Britain (UK)
78
Adjuvant:
saponin
Adjuvant: ?
(Contact
manufacturer)
Adjuvant:
saponin
Adjuvant:
(contact
manufacturer)
Sheep, goats, pigs:
0.5 ml s.c.
Cattle: 1 ml s.c.
Small animals: 1 ml
Sheep, pigs:
2 ml
Cattle, horses; 2 ml
Sheep, goats, pigs:
1 ml s.c.
Cattle, horses: 2 ml s.c.
Sheep, goats, pigs, cattle,
horses: 2 ml
Cattle and horse: 20 x106
Subcutaneous (2ml)
Sheep and Goats: 10x106
Subcutaneous (1ml)
Annual revaccination
50ml flasks
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
MANUFACTURERS OF VETERINARY ANTHRAX VACCINES
Country
Colombia
S.A. cont.
Czech
Republic
Ethiopia
France
Hungary
Manufacturer
Description
LAVERLAM
Carrera 5 No. 47-165
Salomnia Industrial
Apartado aéreo 9985
Cali. Valle del Cauca
Phone/fax: (+57-2)
4474411/4474409
Sterne/Alumini
um hydroxide
Laboratorios V.M.
Autopista Norte kilómetro 19
Urbanización Industrial El Pilar
Apartado aéreo 15453
Phone/fax: (+57-1)
6760901/6760823
Santafé de Bogotá.
Sterne/Saponin
VECOL
Av. El Dorado No. 82-93
Apartado aéreo 7476
Phone/fax: (+57-1)
2633100/2638331
Santafé de Bogotá.
E-mail: Vecol@insat.net.co
Sterne/Buffered
glycerin
Bioveta plc
Komenského 212
683 23 Ivanovice na Hané
Tel.: +42 507 933 21-4
Fax: +42 507 932 84 (or 94)
Strain: 34F2
National Veterinary Institute
P.O. Box 19
Bebre – Zeit
Tel.: +251 133 8388
Fax: +251 133 8844
Strain: 34F2
Rhone Mérieux
17 Rue Bourgelat
BP 2006
69227 Lyon Cedex 02
Tel.: +33 7272 3000
Fax: +33 7272 3069
Strain: 34F2
Phylaxia-Sanofi Veterinary
Biologicals Co Ltd
P.O. Box 68
1475 Budapest
Tel.: +36 1 262 9505
Fax: +36 1 260 3889
Strain: 34F2
Dose*
Cattle: 20x106
Subcutaneous (2ml)
Other species: 10x106
Subcutaneous (1ml)
Annual revaccination
50ml flasks
Cattle and horse: 20x106
Subcutaneous (2ml)
Sheep and goats: 10x106
Subcutaneous (1ml)
Annual revaccination
10, 20, 50 and 100ml flasks
Cattle and horse : 1520x106 Subcutaneous (2ml)
Sheep, goats and pigs: 710x106 Subcutaneous (1ml)
Annual revaccination
50ml flasks and box of ten,
10ml flasks
Adjuvant:
saponin
Sheep, goats, pigs, cattle,
horses: 1 ml s.c.
Name of
product:
"Antraxen inj.ad
us. vet."
Adjuvant:
saponin
Adjuvant:
saponin
Adjuvant:
saponin
Sheep, goats, pigs: 1 ml
Cattle, horses: 2 ml
Sheep, goats, pigs: 1 ml
Cattle, horses: 2 ml
Sheep, goats: 0.5 ml
Cattle: 1 ml
79
Appendix V – Vaccines
MANUFACTURERS OF VETERINARY ANTHRAX VACCINES
Country
India
Indonesia
Italy
Japan
Kenya
Korea (South)
Nepal
80
Manufacturer
Description
Dose*
Institute of Veterinary Preventive
Medicine
Ranipet - 632 402
North Arcot Ambedkar District
Tamil Nadu
Tel.: +91 4172 22633
Strain: 34F2
Pusat Veterinaria Farma
Jalan Jenderal A. Yani 68-70
Kotak Pos WO.3
Surabaya 60231
Tel.: +62 31 816123
Fax: +62 31 814126
Strain: 34F2
Istituto Zooprofilattico
Sperimentale della Puglia e della
Basilicata
Via Manfredonia, 20
I-71100 Foggia
Tel: +39 0881 786 111/786 300
Fax: +39 0881 786 362
Strain: Pasteur 2
The Chemo-Sero-Therapeutic
Research Institute
668 Okubo Shimizu
Kumamoto 860
Tel.: +81 96 344 1211
Fax: +81 96 345 1345
Strain: 34F2
Cooper Kenya Ltd
Wellcome Centre
Kaptagat Road (off Waiyaki
Road), P.O. Box 40596
Nairobi
Tel.: +254 580612
Fax: +254 632123
Strain: 34F2
Choong Ang Animal Disease
Laboratory
Seo TaeJeon P.O Box 312
408-1 Sa Jung Dong
Choong-Ku
TaeJeon
Tel.: +82 42 581 2991
Fax: +82 42 581 5856
Strain: 34F2
Adjuvant:
saponin
Sheep, goats, pigs:
1.0 ml
Cattle, horses: 2.0 ml
Biological Products Div.
Central Animal Health Centre
Veterinary Complex
Tripureswor
Kathmandu
Tel.: + 977 211 335
Strain: 34F2
All species: 1 ml
Adjuvant: none
Adjuvant:
saponin
Adjuvat:
saponin
Strain: Pasteur 1
Sheep, goats: 1 ml injected
s.c. in tail fold
Cattle, pigs, horses,
camels: 1 ml s.c.
Elephants: 1 ml s.c. with
second dose of 3 ml after
1 month
Sheep, goats, pigs: 0.5 ml
s.c.
Cattle, horses: 1 ml s.c.
Cattle (> 6 months): 0.25 l,
s.c.
Cattle (< 6 months), sheep:
0.125 ml, s.c.
Horse, goats: 0.125 ml, s.c.
Adjuvant:
saponin
Adjuvant: none
Adjuvant: ?
Adjuvant:
saponin
Cattle & horses only:
0.2 ml s.c.
Sheep, pigs: 0.5 ml s.c.
Cattle, horses: 1 ml s.c.
(It is recommended that
goats should not be
vaccinated without first
consulting veterinary
surgeon)
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
MANUFACTURERS OF VETERINARY ANTHRAX VACCINES
Country
Manufacturer
Description
Dose*
Institute for Animal Science and
Health
P.O. Box 65 (Edelhertweg 15)
8200 AB Lelystad
Tel.: +31 320 238238
Fax: +31 320 238 050
Strain: 34F2
Pakistan
Vaccine Production Laboratories
Brewery Road
Quetta
Details not
obtained
România
Institutul National de Medicina
Veterinara "Pasteur"
77826 Sos. Giulesti 333
Sector 6
R-7000 Bucuresti
Tel.: +40 1 220 6486
Fax: +40 1 220 6915
Strain: 1190 R –
Stamatin
South Africa
(Republic of)
Onderstepoort Biological
Products
Private Bag X 07
0110 Onderstepoort
Tel.: +27 12 529 9111
Fax: +27 12 546 0216
Telex: 322088 SA
Strain: 34F2
Turkey
Etlik Hayvan Hastaliklari
Arastirma Enstitüsü
06020 Ankara
Tel.: +90 4 321 1200
Fax: +90 4 321 1755
Strain: 34F2
All Russian Institute of
Veterinary
Virology and Microbiology
Pokrov Biological Plant
601121, pos. Volginskiy,
Vladimirskaya oblast
Tel.: +7 09243 6-7110
Strain: 55
Four versions to meet
different needs
Doses vary with different
versions of the vaccine.
(Further information from
Dr V. Gavrilov at given
address)
Interifa SA,
Rhône Mérieux
José Ma. Penco 3427
11700 Montevideo
Tel.: +598 29 70 91
Fax: +598 23 78 52
Strain: 34F2
Sheep, goats, pigs:
1 ml s.c.
Cattle, horses: 2 ml s.c.
Netherlands
Russian
Federation
Uruguay
Adjuvant:
saponin
Small animals: 0.5 ml s.c.
Sheep, goats, pigs, young
foals and calves:
0.5 ml s.c.
Adult cows, horses:
1 ml s.c.
Adjuvant:
saponin
Cattle (> 2 months):
0.5 ml s.c.
Sheep, pigs
(> 2 months): 0.2 ml s.c.
Horses (>6 months):
0.2 ml s.c.
Goats (>2 months):
0.1 ml s.c.
All species: 1ml s.c.
Adjuvant:
saponin
(Al[OH]3 for
goats)
Adjuvant:
saponin
Adjuvant:
saponin
Sheep, goats, pigs:
0.5 ml s.c.
2-6 month old lambs, kids:
0.25 ml s.c.
Horses, mules, donkeys,
cattle , camels: 1 ml s.c.
2-6 month old horses,
donkeys, mules, calves: 0.5
ml s.c.
81
Appendix V – Vaccines
MANUFACTURERS OF VETERINARY ANTHRAX VACCINES
Country
Uruguay cont.
USA
Zambia
Manufacturer
Laboratorio Prondil S.A
Barros Arana 5402
C.P. 12200
P.O.Box 15147 Dto.5
Montevideo
Uruguay
Tel : +598 25 13 32 54
Fax: +598 25 13 32 52
E-mail: pron@netgate.com.uy
Description
Dose*
Anthrax only
Strein : 34F2
Adjuvant:
saponin
1. Sheep, goats, pigs:
0.5 ml s.c.
« Blanthrax »
Combination
anthrax and
blackquarter
Cattle, sheep, goats only:
2 ml s.c.
(pending
registration)
« Supervax »
Combination
anthrax,
blackquarter,
botulism C,D
(S. African
strains)
Cattle, sheep, goats only :
2 ml s.c.
Colorado Serum Co.
4950 York Street
Denver, CO 80216-0428
Tel.: +1 303 295 7527
Fax: +1 303 295 1923
Strain: 34F2
Central Veterinary Research
Institute
P.O. Box 33980, Lusaka
Tel.: +260 1
216031/211389/233445
Fax: +260 1
2334444/236283/252608
E-mail: cvri@zamnet.zm
Strain: 34F2
Adjuvant:
saponin
Adjuvant:
saponin
All domestic farm animals:
1 ml s.c.
Booster recommended
2 to 3 weeks after first dose
in heavily
contaminated areas
Sheep, goats, pigs:
0.5 ml
Cattle, horses: 1 ml
*s.c. = subcutaneous
No reply was received from a number of these companies/institutes to a questionnaire sent to obtain
confirmation of this information, but we have reason to believe they manufacture and/or distribute the
vaccine in their regions. Other bodies included in the previous edition of this document (Turnbull, 1993),
but for whom no direct or indirect information was available, have not been included in this table.
82
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
A.V.4
Manufacturers of human anthrax vaccines
MANUFACTURERS OF HUMAN ANTHRAX VACCINES
Country
Britain (UK)
Manufacturer
(For UK Department of Health)
CAMR
Porton Down
Salisbury, Wiltshire SP4 0JG
Description
Dose*
Alum precipitated
filtrate of strain
34F2 culture
3 doses of 0.5 ml i.m. at
intervals of 3 weeks
followed by a fourth dose
after an interval of
6 months. Reinforcing
doses of 0.5 ml i.m.
should be given annually.
Enquiries about obtaining
vaccine:
WITHIN UK to:
Central Vaccine Unit
Department of Health
Room 715, Wellington House
133-155 Waterloo Road
London SE1 8UG
Tel.: 071 972 4477
OUTSIDE UK to:
Porton Vaccines
Porton Down
Salisbury, Wiltshire SP4 0JG
Tel.: +1980 610896
Fax: +1980 610896
China
(People's
Republic)
Lanzhou Institute of Biological
Products
118 Yan Chang Road
Lanzhou, Gansu 730046
Tel.: +86 931 8888311
Fax: +86 931 417199
Live spore
suspension of
strain A16R
Single dose by
scarification of a 20 Fl
(approx.) droplet in skin.
Russian
Federation
Institute of Microbiology
010024 Kirov
Oktyabrskiy Prospect 119
Tel.: +7 62 84 08
Live spore
suspension of strain
STI (Sanitary
Technical Institute),
Nikolai Ginsberg
1940
Initial 2 doses 21 days
apart and single annual
booster doses.
Administered by
scarification of one or two
10-20 Fl droplets in skin,
or s.c. 0.5 ml
USA
Michigan Biologic Products
Institute
3500 N. Martin Luther King Jr
Blvd, P.O. Box 30035
Lansing, MI 48909
Tel.: +1 517 335 8450
Fax: +1 517 335 9486
Aluminum
hydroxideadsorbed filtrate of
strain V770 culture
3 s.c. doses, 0.5 ml each,
given 2 weeks apart
followed by 3 additional
s.c. injections, 0.5 ml each,
at 6, 12 and 18 months.
Subsequent booster
injections of 0.5 ml at
one-year intervals.
*s.c. = subcutaneous;
i.m. = intramuscular
83
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
Appendix VI
Contingency Plan for the Prevention
and Control of Anthrax
(modified from Whitford 1987)
A.VI.1
Action in the event of an outbreak of anthrax
in livestock
An exemplary control programme was instituted by the Department of Natural Resources and
Environment, Victoria, Australia, in response to an outbreak of anthrax in cattle during the first
half of 1997 affecting some 83 farms in the Goulburn Valley. This has now been established as
an Australian standard and would appear to serve well as a global model for anthrax control.
The following summary, based on the respective report (unpublished) of the Chief Veterinary
Officer (Dr A.J. Turner), Victoria, is included here by kind permission.
On each affected farm, the following measures must be applied:
1.
The carcasses of infected cattle are to be either burnt at the site of death and the ashes buried
deeply, or wrapped in double thickness plastic, to prevent spilling of body fluids, and
removed to a more suitable site (e.g. a quarry) where they are burnt and the ashes
buried. (Consideration may be given to removing the carcasses to suitable
commercial incinerators or rendering plants)
2.
The site where the animal died is to be disinfected with 5% formaldehyde after
disposal of the carcass.
3.
All other animals in the affected herd are to be vaccinated.
4.
Affected properties are to be quarantined for at least 20 days after the last case or
6 weeks after vaccination, whichever is later.
5.
Any milk collected from a cow showing signs of anthrax within 8 hours of milking is
to be destroyed, along with any other milk that may have been mixed with the
suspect milk.
6.
Any movement of susceptible livestock, or risk items (hides, skins, carcasses, etc.)
that have left the property in the 20 days before the first anthrax case, are to be traced,
and appropriate action taken if necessary.
85
Appendix VI – Contingency Plan for the Prevention and Control of Anthrax
7.
As far as possible, vehicles should remain on made roads in infected and vaccinated
farms; where vehicles have to enter the pasture fields, the vehicle should be
disinfected before exiting the property by washing down with water and detergent to
remove mud followed by a disinfectant wash.
8.
People entering infected properties are required to wear protective clothing and
footwear which are disinfected before leaving the property.
9.
All cattle on neighbouring properties should also be vaccinated and the property
quarantined for the appropriate period to cover the witholding period for the vaccine.
Generally three weeks is regarded as a satisfactory time period, but other
considerations, such as the requirements of countries to which meat from such farms
is to be exported, have to be taken into account in deciding the appropriate period.
10. A buffer zone, 20-30 km wide, is to be established around the infected property (-ies)
within which all cattle and exposed sheep are vaccinated and quarantined.
A.VI.2
Other actions in the event of a case, or cases, of anthrax
in livestock
The appearance of infection in animals from a previously uninfected environment (usually a
farm) may be dealt with in the following ways:
86
1.
Identify, isolate and remove apparently healthy animals, and monitor these carefully
for signs of illness (see 5 below).
2.
Decontaminate soil, bedding, unused feed, manure, etc., or disinfect premises that
may have become contaminated by exudations from the dying or dead animals (see
Sections 8.3.1/2/5-8).
3.
Avoid any unnecessary ante- and post-mortem operation in animals on the premises
(see Section 8.1).
4.
Destroy carcasses and their parts by burning, removal for rendering or, as a last
resort, (see Section 8.1) deep burial after disinfection, preferably with formalin
solution.
5.
Vaccinate all susceptible animals if there is reason to believe they continue to be
exposed to the source of the incident. Where high exposure is suspected or certain,
more rapid protection may be obtained by antibiotic therapy. Antibiotics and vaccine
should not be administered simultaneously (see Section 7.1 and Appendix V);
6.
Control scavengers and possible vectors, such as flies, rodents and birds.
7.
Carry out an epidemiological investigation to detect the source of infection (history of
site, feed, disturbance of the environment, etc.) to identify the source of the incident.
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
8.
Take proper measures to avoid the contamination of water and soil and to prevent
the spread of the infection to other farms and environments. Disturbed soil thought
to be related to the incident should be fenced off and, ideally, not used for grazing
again, at least until well overgrown again with vegetation, preferably of the type that
inhibits access by susceptible animals.
9.
Alert public health authorities.
A.VI.3
Guidance on actions relating to milk from herds/flocks in
which anthrax has occurred
Action to be taken on milk from a herd or flock experiencing cases of anthrax infection
occasionally presents a dilemma for health authorities. Wasteful destruction of large quantities
of milk, and consequent financial losses, can be avoided by considering the following:
1.
Animals with anthrax infection do not usually discharge the infecting organism in
their milk. Secretion of milk would normally be expected to cease with onset of
bacteraemia and illness. The organism would only gain entry to the milk secreting
glands through breakdown of blood vessel walls at terminal stages of the disease,
long after secretion of milk has stopped. Milk from other healthy animals in the
herd/flock poses no risk of carrying anthrax organisms.
2.
In the unlikely event of an exception to the rules given in 1. above occurring, and
anthrax organisms reaching the milk before secretion has ceased, it must be
remembered that
•
the organisms are in vegetative form,
•
they will have no opportunity to sporulate as a result of having minimal aeration
and, where commercial processing follows, of rapid cooling to refrigeration
temperatures,
•
the vegetative forms die quite rapidly in the milk (Bowen and Turnbull, 1992) and
will be killed immediately by pasteurisation,
•
3.
any anthrax organisms reaching the bulked milk will have been considerably
diluted; the infectivity of anthrax organisms for humans by the oral route is very
low. Vegetative forms will be killed by the gastric juices.
We are unaware of any instances on record of human anthrax cases resulting from
handling or consumption of milk from herds/flocks experiencing anthrax and
processed dairy products have never been associated with human anthrax.
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Appendix VI – Contingency Plan for the Prevention and Control of Anthrax
Action on the part of farmers/owners and public health authorities aimed at reducing the
minimal risk to zero risk should consist of:
•
milking only health animals; animals showing signs of illness should be set aside for
appropriate treatment and the milk from those animals, and utensils used in its
collection, should be sterilised,
•
ensuring hygienic practices are in place which prevent the environment of the
premises becoming contaminated with anthrax spores and, further, prevent milk
becoming contaminated from the environment,
•
ensuring all milk is rapidly cooled to 4 C or less within 4 hours of milking and is held
at this temperature until processed at a licensed dairy plant,
•
pasteurisation of all milk before processing for human or animal consumption
If the veterinary inspector is satisfied these requirements have been met, milk from healthy
animals in herds/flocks in which cases of anthrax have occurred need not be excluded from
processing and bulked milk containing such milk need not be condemned.
A.VI.4
Precautions for exposed personnel
Persons who have to handle animals known to be, or suspected of being infected with anthrax,
or carcasses from such animals, or parts from such carcasses, should take the following
precautions. They should:
1.
be vaccinated against anthrax if their exposure is frequent and if the human vaccine
is available (see Appendix V);
2.
avoid all blood-spilling operations (slaughtering included) on infected or suspect
animals/carcasses;
3.
use protective clothing such as strong gloves, boots, coveralls, etc., as appropriate, to
avoid direct contact with infected/contaminated materials. Cuts, abrasions, or other
lesions should be properly dressed before putting on the protective clothing. The
equipment used must be adequately disinfected or appropriately destroyed (see
Section 8.3.9);
4.
avoid any contact with other persons (family included) or animals, without first
changing clothing, washing hands, and taking appropriate disinfection measures (see
Section 8.3.9);
5.
report to a physician any suspicious symptoms appearing after contact with infected
animals or materials.
Where there is a risk of aerosolisation of spores, further precautions should be considered, such
as damping down the material, possibly with 5% formalin, wearing of face masks, etc.
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Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
Appendix VII
Model Country Programme
A.VII.1
Background
At the creation of the "WHO working group on anthrax control and research" in November,
1990, a long-term 3-phase "model country programme" was formulated to address the need for
improved surveillance and control of anthrax throughout the world (WHO, 1991). The purpose
of this was to work out the design and method of implementation in practice of a surveillance
and control programme in certain "model countries" and then to put this programme forward
as a template to guide other countries in formulating their own national policies with regard to
anthrax surveillance and control.
In the event, following a meeting of the working group in Mongu, Western Zambia,
23-28 September 1992, the Department of Veterinary and Tsetse Control Services in Zambia,
with the aid of the Dutch Government sponsored Livestock Development Project Phase II, took
up the challenge in the Western Province. A series of templates for national anthrax control
programmes has now been constructed for the benefit of other countries on the basis of the
experience gained in Western Province. This has been demonstrated at Southeast Asia and
Central Asia inter-regional WHO-sponsored anthrax workshops in Kathmandu, Nepal,
9-11 March 1997 (Joshi, 1997) and Almaty, Kazakhstan, 5-6 October 1997 (Cherkasskiy, 1997).
In general, the problems in controlling anthrax in many African countries, and possibly a
number of countries in other parts of the world, stem from:
•
the custom within many communities of butchering, eating and distributing meat
from sudden death animals and utilising or selling their hides, bones, etc.
•
lack of cooperation by farmers/owners over reporting sudden deaths and over
vaccination
•
failure or long delays in diagnosis due both to poor communication and inadequate
local laboratory training/facilities
•
frequent failure to implement policies on disposal of carcasses and subsequent
disinfection and decontamination as a result of shortage of veterinary staff, lack of
fuel or unavailability of disinfectants.
The appropriate regulations and guidelines in regard to surveillance, reporting and control
measures for anthrax are generally in place in these countries; the problem lies with the
implementation of these regulations and guidelines. The templates given below, therefore, in
specifying the classical actions involved for an effective control programme, do not add
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Appendix VII — Model Country Programmes
anything which is new or revolutionary, but rather supply a means for veterinary and public
health authorities to examine the shortfalls occurring in practice in their countries, and which
are the cause of the continuing incidence of anthrax they are experiencing.
Every country suffering from frequent incidents or outbreaks of anthrax will have its own
underlying related problems. In the templates which are given below, the problems faced by
veterinary and public health authorities in Western Province, Zambia, are inserted to supply
examples of how the templates might be used by other countries when analysing their own
problems for the purpose of formulating their control programmes and policies.
The templates are designed to enable a simple comparison between classical, or textbook,
approaches to control and what actually occurs in reality in a country. Action to reduce the
discrepancy between the ideal and the real will lead to reduced incidence of anthrax.
A.VII.2
Templates for control problems illustrated with the
experience gained in Western Province, Zambia
The situation in Western Province, Zambia
In Western Province, cattle are often kept by people who are not the actual owners, whether for
long term (mafisa), or temporary caretaking in the uplands (bulisana), or in the short term for
ploughing or manuring (kutulisa). In the event of an animal dying, the owner must be
presented with the hide or head as identification. Thus cattle that have died unexpectedly are
dragged to the village or they are skinned or butchered on the spot and the meat, hide and head
transported to the village.
Efforts to advise the local communities on the dangers of such behaviour meet resistance as it is
thought burying or burning the carcass is a waste. It is recognized that the obviously affected,
swollen spleen represents serious danger and this is fed to dogs or buried. However, in view of
the suddenness of illness and death, the meat looks good and is not associated with high risk of
illness. Of many people who eat such meat, usually few get disease and very few actually die.
Indeed, if 50 people ate the meat and 2 died, then the community may not accept that the meat
was responsible for the two deaths. The value of the meat, therefore, is seen to greatly outweigh
the risks of members of the community contracting the disease.
Burying requires extra labour and burning not only requires extra labour but also wood as well
which is not available in some areas where outbreaks occur. For these reasons anthrax carcasses
are almost always opened up and the meat consumed. Since the affected communities are
frequently in remote and inaccessible places, reports reach veterinary services much later and
hence there is little supervision of the disposal of carcasses.
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Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
In the following templates, the blank boxes on the right are for the benefit of the user of this
document in assessing the surveillance and control situation within his or her country or area.
Template 1: Surveillance
Ideal
All unexplained livestock
deaths or suspected cases
must be investigated with
laboratory support
Constraints
Western Province situation
The term "all" is unachievable,
although it should be possible to
achieve many more
Western Province situation
•
Distances involved
•
Remoteness in some cases
•
Lack of transport
•
Importance
Our situation
(This space for user
of template)
Our situation
(This space for user
of template)
Delays in specimen delivery
•
Laboratory materials unavailable
•
Confusion as to cause of death is avoided
•
Demonstrates that control measures are working
Additional notes: Every unexpected death in livestock should automatically result in a blood
smear for examination by veterinary authorities at the earliest opportunity. A person of
appropriate standing in each community could perhaps be recruited to implement this; he/she
should be given adequate instruction, including on safety issues. If vaccine is available, the
individual concerned should be offered this.
Since it is a frequent experience that smears may fail to reveal anthrax bacilli, especially if the
carcass was not fresh at the time of making the smear, laboratory culture should be regarded as
an essential back-up procedure for diagnosis. This should be made possible by provision of the
appropriate equipment, materials and instruction at least at the District Veterinary Laboratory
level.
The development of "at-the-site" test systems not requiring expensive equipment such as a
microscope should be regarded as an urgent priority. As discussed elsewhere in this document,
this has now been done (Burans et al., 1996) and awaits the stage where it can be fully evaluated
in the field and made widely available.
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Appendix VII — Model Country Programmes
Template 2: Reporting
Ideal
Reporting and information
must be efficient,
involving
•
keeping good records
•
mandatory reporting of
deaths
Western Province situation
Reporting does occur, but
•
efficiency needs to improve
•
cooperation between the local
established social structure
(Barotse Royal Establishment) and
the veterinary public health
officials may be the way to
improve this
Constraints
Importance
Our situation
Western Province situation
•
the size of the areas being
monitored
•
the remoteness of some of the
villages
(This space for user
of template)
Our situation
(This space for user
of template)
•
the inaccessibility of many of the
communities
•
shortage of basic materials at the
veterinary assistant level
•
Success of control efforts cannot be monitored without good
reporting
Additional note: A concerted effort should be made to ensure that hospitals and human clinics
inform veterinary officials upon seeing a case of anthrax.
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Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
Template 3: Disposal
Ideal
After confirmation as
being a case of anthrax, a
carcass should not be
opened and should be
burnt (or, the less
preferred option, buried)
Constraints
Importance
Western Province situation
Our situation
Many carcasses are butchered and sold
for human consumption. The meat and
hides are seen as good and their value
is seen as outweighing risks of serious
illness
(This space for user
of template)
Burning is not feasible due to shortage
of fuel
Western Province situation
•
attitudes of stock owners
•
tradition of keeping head, meat and
hides of animal that has died by
caretakers to present to owners
when they return from absence
Our situation
•
lack of understanding why only
some of those handling an anthrax
carcass or eating the meat acquire
the disease
•
avoidance of environmental contamination
•
avoidance of spread of anthrax
(This space for user
of template)
Additional notes: Options on the best official approach to dealing with anthrax carcasses in
developing country situations range from leaving it unopened for several days to allow
putrefaction to kill the anthrax bacilli within the carcass to a mandatory rendering policy with
many other approaches in between. Research is needed to determine under what conditions
rendering policies might be established and also on practical and effective incineration
procedures appropriate to the local circumstances.
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Appendix VII — Model Country Programmes
Template 4: Disinfection
Ideal
Disinfectants should be
held in reasonable
quantities at field stations.
Veterinary assistants and
stock owners should be
trained in their use
Western Province situation
At this point in time, this is not
possible
Constraints
Importance
Our situation
Western Province situation
(This space for user
of template)
Our situation
•
Lack of availability of suitable
disinfectants
•
Cost
•
Hazards posed by the appropriate
disinfectants
•
The types of premises where
anthrax carcasses are handled
•
Disinfection is a useful control measure
•
It should be introduced when possible in endemic areas where this is
currently not possible
(This space for user
of template)
Additional notes: Provision, supply and storage of appropriate types of disinfectants are clearly
a problem for developing countries principally because these have to be imported at
unacceptable cost. Research is needed on the design of disinfection procedures applicable to the
economic and other conditions pertaining in such countries.
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Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
Template 5: Vaccination
Ideal
· A vaccine meeting
acceptable standards
should be available
•
•
Field officers should
have the necessary
storage facilities
A contingency stock
should be readily
available
Constraints
Importance
Western Province situation
•
Variable and inadequate
vaccination coverage
•
Intermittent supply of the vaccine
•
Limited storage facilities at field
level
•
Inadequate duration of vaccine
campaigns
Western Province situation
•
Perceived cost
•
Free vaccination → retroactive
immunisation → perceived failure
→loss of confidence in vaccination
on the part of the stock owner
Our situation
(This space for user
of template)
Our situation
(This space for user
of template)
Vaccination is the hub of anthrax control, at least in endemic areas
Additional notes: For maximum success, vaccination as a control measure must be applied
TOGETHER WITH other control measures and must be continued for a full specified period
(frequently 3 years is the period specified).
It makes sense in many endemic regions to use combined vaccines, such as Black
Quarter/Anthrax vaccine.
Vaccines are generally available (see Appendix V). Problems largely relate to farmers' attitudes
(Dietvorst, 1996a), the cost and the logistics of carrying out and evaluating the effectiveness of
vaccination campaigns. Examples of the sort of resistance on the farmers' part to vaccination
and the rationale for this resistance are well covered by Dietvorst (1996a). As a first example,
vaccination initiated in response to an outbreak has led to the situation in which the vaccine has
been administered to animals already infected and which have died shortly after. This results
in, at best, loss of faith in the vaccine and, at worst, a belief that the vaccine killed the animal(s).
A second example is a belief that animals must be rested for two weeks after vaccination;
frequently farmers feel they are unable to cease work for this period.
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Appendix VII — Model Country Programmes
Template 6: Education
Ideal
Western Province situation
Educational material on
anthrax should be
supplied to field or other
appropriate stations for
distribution in the affected
community
Successful. Booklet, poster, radio
programmes have been prepared and
have reached the relevant communities
(see Figure 4)
Constraints
Western Province situation
Importance
Needs to be continued, expanded
(more issues) and extended (more
affected people reached)
•
Distances involved and
inaccessibility of some communities
•
Printing and paper costs
•
Dissemination costs
Our situation
(This space for user
of template)
Our situation
(This space for user
of template)
The relevant individuals gain a better understanding of the rationale
AND the limitations of control actions
Additional notes: Inherent in all the control measures is the underlying need for educational
programmes and materials. Of foremost importance is education of the farmer/owner to
recognize and report suspected anthrax and take proper action over the disposal of the carcass.
Appropriate education must also be available for instruction of veterinary, medical and other
officials in confirmation of diagnosis and correct action thereafter.
The clear need for informational broadsheets, manuals, videos and films for disseminating
information at courses, seminars and village meetings has been addressed in an exemplary
manner in Western Zambia (Dietvorst, 1996a), where posters, booklets and a radio play
(Dietvorst, 1996b) have been developed (Figure 4).
Intersectoral cooperation
Good communication and cooperation (including sharing laboratory facilities and knowledge)
between veterinary, medical and wildlife services are essential to control of anthrax. Such
communication and cooperation falls short of ideal in many countries at present.
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Guidelines for the Surveillance and Control of Anthrax in Humans and Animals
Figure 4
The pictures feature in a book and on a poster, designed to convey in an interesting manner to
those likely to encounter anthrax, the important points about the disease which they should be
aware of and how it can be prevented. The points are made by telling the story of the problems
the Liseli family suffered following the death of one of their cows from anthrax.
Drawings by Lou Sifuniso, text by Désirée Dietvorst (Dietvorst, 1996b). Reproduced by kind permission
of the Livestock Development Programme, P.O. Box 910428, Mongu, Zambia, and RDP Livestock
Services B.V., Zeist, The Netherlands.
One of Mr and Mrs Liseli's cows has died unexpectedly of anthrax (top left). Meat is precious
and the carcass looks good, so Mr Liseli decides to cut it up so that he can take it to the village
(top right). The meat looks fine and smells all right, so Mr Liseli and his son, Likando, lift the
pieces onto their sledge and take them back to the village (row 2, left). Once at the village,
Mrs Liseli takes some of the meat and starts to prepare dinner while Mr Liseli hangs strips of
the meat and other parts of the carcass out to dry (row 2, right). They enjoy a nice dinner (row 3,
left), though Sespio, Likando's younger brother, is too small to eat meat. A few days later, Mr
and Mrs Liseli fall ill and have large sores, Mr Liseli on his neck, Mrs Liseli on her arm. Likando
is even more ill. They do not know what has made them ill and they decide to go to the
hospital (row 3, right). Despite treatment, Likando dies (bottom left). In the meantime, the
veterinary assistant has come to visit the farmers. He explains that anthrax can spread quickly
when carcasses are opened and the soil becomes infected with spores. He tells them that the
carcasses should be buried very deep in the ground so that dogs and hyenas cannot dig them
up again and that their animals can be vaccinated against anthrax to prevent more of them
getting the disease and dying (bottom right).
97